Provider Demographics
NPI:1649257163
Name:JACKSON, GREGORY PAUL (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HOLLISTER DR
Mailing Address - Street 2:SUITE G-18
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5263
Mailing Address - Country:US
Mailing Address - Phone:847-968-5300
Mailing Address - Fax:847-968-4311
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:SUITE G-18
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-968-5300
Practice Address - Fax:847-968-4311
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35393174400000X
IN01059554A174400000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21110Medicare ID - Type UnspecifiedAHRC
ILG15009Medicare UPIN
ILK06614Medicare ID - Type UnspecifiedGRC LAKE COUNTY
ILK22464Medicare ID - Type UnspecifiedGMI COOK COUNTY
ILK15723Medicare ID - Type UnspecifiedMIDWESTERN REGIONAL
ILK06607Medicare ID - Type UnspecifiedGRC COOK COUNTY
ILK07141Medicare ID - Type UnspecifiedGMI LAKE COUNTY