Healthcare Provider Details

I. General information

NPI: 1073668810
Provider Name (Legal Business Name): ANN WILBORN JACKSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18860 HAMLIN AVE
FLOSSMOOR IL
60422-1046
US

IV. Provider business mailing address

18860 HAMLIN AVE
FLOSSMOOR IL
60422-1046
US

V. Phone/Fax

Practice location:
  • Phone: 708-922-0741
  • Fax: 708-922-0196
Mailing address:
  • Phone: 708-922-0741
  • Fax: 708-922-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: