Individual
MRS. JACKIE LOU ANDERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
101 SHORELAND RD, MACHESNEY PARK, IL 61115-2833
(815) 633-1173
Mailing address
101 SHORELAND RD, MACHESNEY PARK, IL 61115-2833
(815) 633-1173
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
222Q00000X
EI
IL
Enumeration date
12/16/2011
Last updated
12/16/2011
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