Healthcare Provider Details

I. General information

NPI: 1447511746
Provider Name (Legal Business Name): ANDREA J JACKSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 RAYMOND DR STE 303
NAPERVILLE IL
60563-9792
US

IV. Provider business mailing address

636 RAYMOND DR STE 303
NAPERVILLE IL
60563-9792
US

V. Phone/Fax

Practice location:
  • Phone: 630-653-4240
  • Fax: 630-315-1505
Mailing address:
  • Phone: 630-653-4240
  • Fax: 630-315-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209009581
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209-009581
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: