Provider Demographics
NPI:1871545772
Name:JACKSON, DENISE L (MD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1748
Mailing Address - Country:US
Mailing Address - Phone:708-756-0100
Mailing Address - Fax:708-709-6353
Practice Address - Street 1:10043 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1272
Practice Address - Country:US
Practice Address - Phone:708-709-9300
Practice Address - Fax:708-709-6353
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00450388/C K6882OtherRAILROAD MEDICARE
IL4673170001OtherDMERC GROUP
ILP00450388/C K6882OtherRAILROAD MEDICARE
ILK27945/203979Medicare PIN
G38216Medicare UPIN