Individual
MISS AMANI DIANNE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3631 213TH ST, MATTESON, IL 60443-2510
(708) 724-4170
Mailing address
1020 PARK DRIVE, P.O. BOX #725, FLOSSMOOR, IL 60422
(708) 724-4170
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
—
—
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
03/24/2016
Last updated
03/24/2016
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