Healthcare Provider Details

I. General information

NPI: 1740351972
Provider Name (Legal Business Name): JACKSON CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 W JACKSON BLVD
CHICAGO IL
60644-4332
US

IV. Provider business mailing address

7257 N LINCOLN AVE
LINCOLNWOOD IL
60712-1810
US

V. Phone/Fax

Practice location:
  • Phone: 773-921-8000
  • Fax: 773-921-3980
Mailing address:
  • Phone: 847-933-2600
  • Fax: 847-933-0686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number5074210001
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number5074210001
License Number StateIL

VIII. Authorized Official

Name: REUVEN LEVITIN
Title or Position: PATIENT ACCOUNTS MANAGER
Credential:
Phone: 847-745-6240