MEDICARE: BREANNA J JACKSON WHNP

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	363LW0102X	Women's Health Nurse Practitioner	209033792	IL

General Provider Information

NPI Number	:	1144162090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNA J JACKSON WHNP

Provider Business Mailing Address
First Line	:	2601 CHAMPAIGN AVE
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-2548
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 N 26TH ST
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-2556
Country	:	US
Telephone Number	:	217-480-5829
Fax Number	:

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

Provider Enumeration Date	:	04/08/2026
Last Update Date	:	04/08/2026

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