Provider Demographics
NPI:1043489875
Name:ALBERT L. JACKSON DDS
Entity Type:Organization
Organization Name:ALBERT L. JACKSON DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST /OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-368-1600
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1803
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-368-1600
Mailing Address - Fax:312-368-1542
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1803
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-368-1600
Practice Address - Fax:312-368-1542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019011493261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental