Provider Demographics
NPI:1184771073
Name:JACKSON, TAMARA (MD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
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 1:469 W HURON ST
Mailing Address - Street 2:APT 810
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3467
Mailing Address - Country:US
Mailing Address - Phone:615-423-9253
Mailing Address - Fax:
Practice Address - Street 1:469 W HURON ST
Practice Address - Street 2:APT 810
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3467
Practice Address - Country:US
Practice Address - Phone:615-423-9253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL3360869172085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program