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NPI Code Detail

MEDICARE: DENISE L JACKSON M.D.

MEDICARE: DENISE L JACKSON M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician036094604IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P00450388/C K6882OTHERILRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
24673170001OTHERILDMERC GROUP

General Provider Information

NPI Number : 1871545772
Entity Type Code : Individual
Provider Name (Legal Business Name) : DENISE L JACKSON M.D.
Provider Business Mailing Address
First Line : 333 DIXIE HWY
Second Line :
City : CHICAGO HTS
State : IL
Zip : 60411-1748
Country : US
Telephone Number : 708-756-0100
Fax Number : 708-709-6353
Provider Business Practice Location Address
First Line : 10043 W LINCOLN HWY
Second Line :
City : FRANKFORT
State : IL
Zip : 60423-1272
Country : US
Telephone Number : 708-709-9300
Fax Number : 708-709-6353
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/17/2006
Last Update Date : 10/17/2012

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