MEDICARE: MRS. NUSHA SYLAJ JACKSON FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP2201X	Ambulatory Care Registered Nurse	041434377	IL
2	363LF0000X	Family Nurse Practitioner	209.021965	IL

General Provider Information

NPI Number	:	1104462738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NUSHA SYLAJ JACKSON FNP

Provider Business Mailing Address
First Line	:	939 W MADISON ST APT 307
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2657
Country	:	US
Telephone Number	:	248-770-5168
Fax Number	:

Provider Business Practice Location Address
First Line	:	1656 N. WELLS
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-3224
Country	:	US
Telephone Number	:	312-643-1333
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2019
Last Update Date	:	09/16/2020

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