Provider Demographics
NPI:1023359510
Name:JACKSON, MARYLYN
Entity Type:Individual
Prefix:
First Name:MARYLYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 LINCOLN HWY
Mailing Address - Street 2:SUITE 113
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1936
Mailing Address - Country:US
Mailing Address - Phone:708-679-0668
Mailing Address - Fax:
Practice Address - Street 1:2555 LINCOLN HWY
Practice Address - Street 2:SUITE 113
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1936
Practice Address - Country:US
Practice Address - Phone:708-679-0668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-017207122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist