MEDICARE: IYANNA JACKSON AADP

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	175F00000X	Naturopath

General Provider Information

NPI Number	:	1962218826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IYANNA JACKSON AADP

Provider Business Mailing Address
First Line	:	125 E 103RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-2713
Country	:	US
Telephone Number	:	773-858-2837
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 E 103RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-2713
Country	:	US
Telephone Number	:	312-554-9177
Fax Number	:

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

Provider Enumeration Date	:	12/05/2024
Last Update Date	:	04/19/2025

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