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 1:2734 W 87TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-3937
Mailing Address - Country:US
Mailing Address - Phone:773-918-4700
Mailing Address - Fax:773-313-3763
Practice Address - Street 1:2734 W 87TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-3937
Practice Address - Country:US
Practice Address - Phone:773-918-4700
Practice Address - Fax:773-313-3763
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2024-07-02
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