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General NPI Number Information
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NPI Number | 1568853984
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Entity Type | Individual
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Provider Name | BRANDI JACKSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 02/06/2015
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 1505 E 53RD ST STE 2E
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City | CHICAGO
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State | IL
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Zip | 60615-4509
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Country | US
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Telephone | 312-337-1073
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Fax |
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Provider Business Mailing Address
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Address Line | 1505 E 53RD ST STE 2E
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City | CHICAGO
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State | IL
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Zip | 60615-4509
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Country | US
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Telephone | 312-337-1073
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 036146681
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License Number State | IL
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