Provider Demographics
NPI:1780366419
Name:JACKSON, HEATHER ANN TAYLOR (APRN, WHNP-BC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN TAYLOR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN, WHNP-BC
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1504 W REYNOLDS ST STE C
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9786
Practice Address - Country:US
Practice Address - Phone:309-604-9505
Practice Address - Fax:309-604-9501
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209026979363LF0000X, 363LP1700X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal