MEDICARE: DENISE L JACKSON M.D.

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	207Q00000X	Family Medicine Physician	036094604	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00450388/C K6882	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	4673170001	OTHER	IL	DMERC GROUP

General Provider Information

NPI Number	:	1871545772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE L JACKSON M.D.

Provider Business Mailing Address
First Line	:	333 DIXIE HWY
Second Line	:
City	:	CHICAGO HTS
State	:	IL
Zip	:	60411-1748
Country	:	US
Telephone Number	:	708-756-0100
Fax Number	:	708-709-6353

Provider Business Practice Location Address
First Line	:	10043 W LINCOLN HWY
Second Line	:
City	:	FRANKFORT
State	:	IL
Zip	:	60423-1272
Country	:	US
Telephone Number	:	708-709-9300
Fax Number	:	708-709-6353

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	10/17/2012

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