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General NPI Number Information
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NPI Number | 1154284453
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Entity Type | Individual
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Provider Name | TYRA JACKSON FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 12/04/2025
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Last Update Date | 12/04/2025
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Provider Practice Location Address
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Address Line | 120 N OAK ST
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City | HINSDALE
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State | IL
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Zip | 60521-3829
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Country | US
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Telephone | 630-856-6825
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Fax |
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Provider Business Mailing Address
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Address Line | 420 S. SCHMIDT RD, SUITE 110
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City | BOLINGBROOK
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State | IL
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Zip | 60440
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Country | US
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Telephone | 630-312-4505
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 209.033340
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License Number State | IL
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