Provider Demographics
NPI:1023558376
Name:JACKSON, ADAM (BMSCD, MBSC, CNIM)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BMSCD, MBSC, CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W CHESTNUT ST APT 2208
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-3347
Practice Address - Country:US
Practice Address - Phone:615-732-9343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2045204R00000X
TN20452084N0600X
173F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173F00000XOther Service ProvidersSleep Specialist, PhDGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty