Basic Information
| Provider Information | |||||||||
| NPI: | 1629078910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | SWAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN MSN BC-FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SWAN | ||||||||
| OtherFirstName: | LINDA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN BSN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 44 GENEVA AVE | ||||||||
| Address2: | |||||||||
| City: | BELLWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601041101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085476931 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11200 W LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154642171 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 05/13/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209002866 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.