Basic Information
| Provider Information | |||||||||
| NPI: | 1013370857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DELOVELY | ||||||||
| MiddleName: | GLORIA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35318 EAGLE WAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606780353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18636 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | HOMEWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604303741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086470571 | ||||||||
| FaxNumber: | 7086470676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2016 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209013987 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | F400298104 | 01 | FPN MEDICARE PTAN | OTHER |