Healthcare Provider Details

I. General information

NPI: 1225790447
Provider Name (Legal Business Name): LASHAWNNA CHANEL JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 06/08/2025
Certification Date: 06/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6307 S STEWART AVE STE 205
CHICAGO IL
60621-3116
US

IV. Provider business mailing address

1044 N FRANCISCO AVE STE 404
CHICAGO IL
60622-2743
US

V. Phone/Fax

Practice location:
  • Phone: 773-868-6824
  • Fax:
Mailing address:
  • Phone: 773-868-6824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277003168
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: