Provider Demographics
NPI:1194372953
Name:JACKSON, LAQUANTA
Entity Type:Individual
Prefix:
First Name:LAQUANTA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 ATHENS RD
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1954
Mailing Address - Country:US
Mailing Address - Phone:708-790-0366
Mailing Address - Fax:708-844-0264
Practice Address - Street 1:2430 ATHENS RD
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1954
Practice Address - Country:US
Practice Address - Phone:708-790-0366
Practice Address - Fax:708-844-0264
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041317085163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse