Provider Demographics
NPI:1912189820
Name:JACKSON, AMY LAUREN (MS)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LAUREN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:101 BURR RIDGE PKWY
Mailing Address - Street 2:STE 150
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0877
Mailing Address - Country:US
Mailing Address - Phone:630-321-3555
Mailing Address - Fax:630-908-5159
Practice Address - Street 1:18210 LA GRANGE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7722
Practice Address - Country:US
Practice Address - Phone:708-478-3111
Practice Address - Fax:708-479-1146
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL147000696231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL529470Medicare UPIN