Provider Demographics
NPI:1144398520
Name:JACKSON, ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
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:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0187
Mailing Address - Country:US
Mailing Address - Phone:708-479-6522
Mailing Address - Fax:708-479-6597
Practice Address - Street 1:939 W NORTH AVE
Practice Address - Street 2:SUITE 750
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7138
Practice Address - Country:US
Practice Address - Phone:312-980-0536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081595207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081595Medicaid
IL036081595Medicaid