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Individual
DENISE L JACKSON
Active
Individual
DENISE L JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036094604
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4673170001
DMERC GROUP
IL
01
—
P00450388/C K6882
RAILROAD MEDICARE
IL
Enumeration date
05/17/2006
Last updated
10/17/2012
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