Healthcare Provider Details

I. General information

NPI: 1720647670
Provider Name (Legal Business Name): MRS. ROBIN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21121 CHRISTINA DR
MATTESON IL
60443-3003
US

IV. Provider business mailing address

21121 CHRISTINA DR
MATTESON IL
60443-3003
US

V. Phone/Fax

Practice location:
  • Phone: 312-218-7409
  • Fax:
Mailing address:
  • Phone: 312-218-7409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number28208253A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041413313
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: