Provider Demographics
NPI:1720598071
Name:DOUGLAS-JACKSON, KESHA (APN)
Entity Type:Individual
Prefix:
First Name:KESHA
Middle Name:
Last Name:DOUGLAS-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:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-0745
Mailing Address - Country:US
Mailing Address - Phone:708-795-0100
Mailing Address - Fax:708-795-0101
Practice Address - Street 1:205 E BUTTERFIELD RD # 297
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5103
Practice Address - Country:US
Practice Address - Phone:708-795-0100
Practice Address - Fax:708-795-0101
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-01
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041410556OtherREGISTERED NURSE