Provider Demographics
NPI:1942253489
Name:JACKSON, DEBRA KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:KAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775 E MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-8820
Mailing Address - Country:US
Mailing Address - Phone:217-864-3737
Mailing Address - Fax:217-864-3468
Practice Address - Street 1:4775 E MARYLAND ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-8820
Practice Address - Country:US
Practice Address - Phone:217-864-3737
Practice Address - Fax:217-864-3468
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.092587OtherMD LICESE
IL384200Medicare ID - Type Unspecified
IL036092587Medicaid