Provider Demographics
NPI:1780055285
Name:JACKSON, JESSICA (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:STOEBERL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:330 MADISON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6572
Mailing Address - Country:US
Mailing Address - Phone:815-725-3440
Mailing Address - Fax:
Practice Address - Street 1:330 MADISON ST STE 104
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6572
Practice Address - Country:US
Practice Address - Phone:815-725-3440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005695363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical