Healthcare Provider Details

I. General information

NPI: 1871120600
Provider Name (Legal Business Name): JESSICA R JACKSON MSN, APRN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 US HIGHWAY 45 N
ELDORADO IL
62930-3770
US

IV. Provider business mailing address

1401 US HIGHWAY 45 N
ELDORADO IL
62930-3770
US

V. Phone/Fax

Practice location:
  • Phone: 618-273-2951
  • Fax: 618-273-2726
Mailing address:
  • Phone: 618-273-2951
  • Fax: 618-273-2726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209021074
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209021074
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: