Provider Demographics
NPI:1346282449
Name:JACKSON, ROBYN A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBYN
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 HOLIDAY DR
Mailing Address - Street 2:SUITE 525
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2241
Mailing Address - Country:US
Mailing Address - Phone:708-898-2613
Mailing Address - Fax:
Practice Address - Street 1:600 HOLIDAY DR
Practice Address - Street 2:SUITE 525
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2241
Practice Address - Country:US
Practice Address - Phone:708-898-2613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095867Medicaid