Healthcare Provider Details

I. General information

NPI: 1457609554
Provider Name (Legal Business Name): PATRICIA NICHOLE JACKSON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 N EOLA RD STE 110
AURORA IL
60502-9619
US

IV. Provider business mailing address

444 N EOLA RD STE 110
AURORA IL
60502-9619
US

V. Phone/Fax

Practice location:
  • Phone: 630-692-5660
  • Fax:
Mailing address:
  • Phone: 630-692-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009753
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277.001274
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: