Healthcare Provider Details

I. General information

NPI: 1871894899
Provider Name (Legal Business Name): TRACY I JACKSON APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CENTRAL ST
EVANSTON IL
60201-1150
US

IV. Provider business mailing address

1810 LAKE STREET
EVANSTON IL
60201
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 847-563-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041315953
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209012646
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: