Provider Demographics
NPI:1619042124
Name:HALL-DAVIS, JACQUELYN (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:HALL-DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1669 WINDHAM WAY SUITE B
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3072
Mailing Address - Country:US
Mailing Address - Phone:618-622-9240
Mailing Address - Fax:618-622-9241
Practice Address - Street 1:1669 WINDHAM WAY SUITE B
Practice Address - Street 2:
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3072
Practice Address - Country:US
Practice Address - Phone:618-622-9240
Practice Address - Fax:618-622-9241
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360802702084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036080270Medicaid
MO3649OtherBCBS MO
ILG36399Medicare UPIN
MO3649OtherBCBS MO