Provider Demographics
NPI:1811350705
Name:JACKSON, PHILIP LARKIN III (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:LARKIN
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:211 E ONTARIO ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3468
Mailing Address - Country:US
Mailing Address - Phone:312-503-7975
Mailing Address - Fax:312-503-5230
Practice Address - Street 1:211 E ONTARIO ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3468
Practice Address - Country:US
Practice Address - Phone:312-503-7975
Practice Address - Fax:312-503-5230
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301505821207P00000X
IN01083406A207P00000X
IL390200000X
IL036.148100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program