Healthcare Provider Details

I. General information

NPI: 1336123041
Provider Name (Legal Business Name): DR MARILYN D JACKSON & ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 E SAUK TRL
SAUK VILLAGE IL
60411-4955
US

IV. Provider business mailing address

PO BOX 1893
CHICAGO HEIGHTS IL
60412-1893
US

V. Phone/Fax

Practice location:
  • Phone: 708-757-3100
  • Fax: 708-757-3272
Mailing address:
  • Phone: 708-757-3100
  • Fax: 708-757-3272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12009402
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number01917207
License Number StateIL

VIII. Authorized Official

Name: MARILYN DENISE JACKSON
Title or Position: DENTIST PRESIDENT OF CORPORATION
Credential: DDS
Phone: 708-757-3100