Provider Demographics
NPI:1093946303
Name:JACKSON, PATTI ANN (DT)
Entity Type:Individual
Prefix:MS
First Name:PATTI
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24543 S MULBERRY LN
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-3708
Mailing Address - Country:US
Mailing Address - Phone:708-672-9882
Mailing Address - Fax:708-672-9883
Practice Address - Street 1:24543 S MULBERRY LANE
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-3708
Practice Address - Country:US
Practice Address - Phone:708-672-9882
Practice Address - Fax:708-672-9883
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist