Provider Demographics
NPI:1447511746
Name:JACKSON, ANDREA J (APN)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 RAYMOND DR STE 303
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-9792
Mailing Address - Country:US
Mailing Address - Phone:630-653-4240
Mailing Address - Fax:630-315-1505
Practice Address - Street 1:636 RAYMOND DR STE 303
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-9792
Practice Address - Country:US
Practice Address - Phone:630-653-4240
Practice Address - Fax:630-315-1505
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-009581363LW0102X
IL209009581363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health