Provider Demographics
NPI:1457923633
Name:JACKSON, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:JACKSON
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:PO BOX 1732
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-7400
Mailing Address - Country:US
Mailing Address - Phone:630-270-9882
Mailing Address - Fax:
Practice Address - Street 1:2501 CHATHAM RD STE N
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4188
Practice Address - Country:US
Practice Address - Phone:630-270-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider