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General NPI Number Information
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NPI Number | 1356929335
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Entity Type | Individual
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Provider Name | TERRANCE LORNE JACKSON DMD
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Gender | Male
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Dates
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Enumeration Date | 03/31/2021
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Last Update Date | 05/10/2023
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Provider Practice Location Address
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Address Line | 6260 N BROADWAY ST
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City | CHICAGO
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State | IL
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Zip | 60660-1968
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Country | US
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Telephone | 773-627-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 169 W HURON ST UNIT 1105
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City | CHICAGO
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State | IL
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Zip | 60654-3612
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Country | US
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Telephone | 706-619-6159
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.033509
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License Number State | IL
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