Healthcare Provider Details

I. General information

NPI: 1104098508
Provider Name (Legal Business Name): GALE VICTORIA JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W MORSE AVE 305
CHICAGO IL
60626-5798
US

IV. Provider business mailing address

2100 PHINGSTEN ROAD
GLENVIEW IL
60025
US

V. Phone/Fax

Practice location:
  • Phone: 773-262-3062
  • Fax:
Mailing address:
  • Phone: 847-657-5786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: