Provider Demographics
NPI:1083612857
Name:JACKSON, DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-6142
Mailing Address - Country:US
Mailing Address - Phone:630-321-8300
Mailing Address - Fax:630-321-8750
Practice Address - Street 1:934 CENTER ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2125
Practice Address - Country:US
Practice Address - Phone:847-429-8750
Practice Address - Fax:847-429-8978
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057410207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03607410Medicaid
IL04532206OtherBLUE CROSS BLUE SHIELD
IL209896Medicare ID - Type UnspecifiedGROUP LOCALITY 99
ILK10454Medicare ID - Type UnspecifiedLOCALITY 99
ILK10453Medicare ID - Type UnspecifiedLOCALITY 15
IL04532206OtherBLUE CROSS BLUE SHIELD
IL209897Medicare ID - Type UnspecifiedGROUP LOCALITY 15