MEDICARE: MRS. AMY LAUREN JACKSON MS

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
1	231H00000X	Audiologist	147000696	IL

General Provider Information

NPI Number	:	1912189820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY LAUREN JACKSON MS

Provider Business Mailing Address
First Line	:	101 BURR RIDGE PKWY
Second Line	:	STE 150
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-0877
Country	:	US
Telephone Number	:	630-321-3555
Fax Number	:	630-908-5159

Provider Business Practice Location Address
First Line	:	18210 LA GRANGE RD
Second Line	:	SUITE 103
City	:	TINLEY PARK
State	:	IL
Zip	:	60487-7722
Country	:	US
Telephone Number	:	708-478-3111
Fax Number	:	708-479-1146

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2007
Last Update Date	:	05/17/2019

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