Provider Demographics
NPI:1982333472
Name:JACKSON, GABRIELLE ELYSE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ELYSE
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 1:2128 E 1525 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565-4537
Mailing Address - Country:US
Mailing Address - Phone:217-273-7930
Mailing Address - Fax:
Practice Address - Street 1:1 MASONIC WAY
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-9467
Practice Address - Country:US
Practice Address - Phone:217-728-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007936225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant