Individual
JACKSON PAUL TATE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2160 S 1ST AVE, MAYWOOD, IL 60153-3328
(888) 584-7888
Mailing address
2160 S 1ST AVE, MAYWOOD, IL 60153-3328
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
125.085170
IL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
08/29/2023
Last updated
04/09/2025
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