Provider Demographics
NPI:1487197745
Name:JACKSON, ALISHA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ALISHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 POUNDSTONE AVE
Mailing Address - Street 2:PO BOX 42
Mailing Address - City:GRAND RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:61325-9100
Mailing Address - Country:US
Mailing Address - Phone:815-236-0024
Mailing Address - Fax:
Practice Address - Street 1:1650 MIDTOWN RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1200
Practice Address - Country:US
Practice Address - Phone:815-220-2645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily