Healthcare Provider Details

I. General information

NPI: 1790347722
Provider Name (Legal Business Name): MICHELLE LYNN JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2019
Last Update Date: 12/14/2024
Certification Date: 12/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8914 N KNOXVILLE AVE
PEORIA IL
61615-1410
US

IV. Provider business mailing address

8914 N KNOXVILLE AVE
PEORIA IL
61615-1410
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-9110
  • Fax:
Mailing address:
  • Phone: 309-691-9110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019281
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209.019281
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: