Healthcare Provider Details

I. General information

NPI: 1063324846
Provider Name (Legal Business Name): LATASHA JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1581 AMARYLLIS DR
ROMEOVILLE IL
60446-5130
US

IV. Provider business mailing address

1581 AMARYLLIS DR
ROMEOVILLE IL
60446-5130
US

V. Phone/Fax

Practice location:
  • Phone: 773-263-3586
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number41367014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: