Basic Information
| Provider Information | |||||||||
| NPI: | 1871545772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO HTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604111748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087560100 | ||||||||
| FaxNumber: | 7087096353 | ||||||||
| Practice Location | |||||||||
| Address1: | 10043 W LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604231272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087099300 | ||||||||
| FaxNumber: | 7087096353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036094604 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00450388/C K6882 | 01 | IL | RAILROAD MEDICARE | OTHER | 4673170001 | 01 | IL | DMERC GROUP | OTHER |