Provider Demographics
NPI:1619038395
Name:JACKSON, RACHEL MOORE (APN)
Entity Type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:MOORE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3741
Mailing Address - Country:US
Mailing Address - Phone:312-572-4554
Mailing Address - Fax:312-572-4559
Practice Address - Street 1:2020 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3741
Practice Address - Country:US
Practice Address - Phone:312-572-4554
Practice Address - Fax:312-572-4559
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004742363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily