Provider Demographics
NPI:1851859706
Name:JACKSON-MURRY, KEISHA SHAVONNE
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:SHAVONNE
Last Name:JACKSON-MURRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 GLADSTONE DR
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1406
Mailing Address - Country:US
Mailing Address - Phone:847-644-6920
Mailing Address - Fax:
Practice Address - Street 1:812 GLADSTONE DR
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1406
Practice Address - Country:US
Practice Address - Phone:847-644-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist