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General NPI Number Information
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NPI Number | 1306395934
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Entity Type | Individual
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Provider Name | ABBIGAIL JACKSON
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Gender | Female
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Dates
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Enumeration Date | 09/23/2016
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Last Update Date | 04/05/2017
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Provider Practice Location Address
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Address Line | 3860 W OGDEN AVE
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City | CHICAGO
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State | IL
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Zip | 60623-2460
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Country | US
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Telephone | 847-588-3024
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Fax |
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Provider Business Mailing Address
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Address Line | 3860 W. OGDEN AVE
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City | CHICAGO
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State | IL
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Zip | 60623
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Country | US
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Telephone | 847-588-3024
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 041413434
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209.014952
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License Number State | IL
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