Provider Demographics
NPI:1215395652
Name:JACKSON, JOELLE (NP)
Entity Type:Individual
Prefix:MS
First Name:JOELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 W IRVING PARK RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3011
Mailing Address - Country:US
Mailing Address - Phone:888-660-4425
Mailing Address - Fax:
Practice Address - Street 1:840 W IRVING PARK RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3011
Practice Address - Country:US
Practice Address - Phone:888-660-4425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-30
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013571363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner