MEDICARE: SARAH A JACKSON M.S., C.G.C

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	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1659302446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH A JACKSON M.S., C.G.C

Provider Business Mailing Address
First Line	:	5841 S MARYLAND AVE
Second Line	:	MC 2115
City	:	CHICAGO
State	:	IL
Zip	:	60637-1447
Country	:	US
Telephone Number	:	773-702-4749
Fax Number	:	773-834-3834

Provider Business Practice Location Address
First Line	:	5758 S MARYLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1426
Country	:	US
Telephone Number	:	773-834-7424
Fax Number	:

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	02/19/2010

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