Provider Demographics
NPI:1801232954
Name:JACKSON, DANELLE LYN (APN)
Entity Type:Individual
Prefix:
First Name:DANELLE
Middle Name:LYN
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 1:626 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2444
Mailing Address - Country:US
Mailing Address - Phone:217-345-7702
Mailing Address - Fax:217-345-7705
Practice Address - Street 1:626 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2444
Practice Address - Country:US
Practice Address - Phone:217-345-7702
Practice Address - Fax:217-345-7705
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99057031A363LF0000X
IL209010509363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400097763Medicare PIN