Provider Demographics
NPI:1356929335
Name:JACKSON, TERRANCE LORNE (DMD)
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:LORNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 W HURON ST UNIT 1105
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3612
Mailing Address - Country:US
Mailing Address - Phone:706-619-6159
Mailing Address - Fax:
Practice Address - Street 1:6260 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1968
Practice Address - Country:US
Practice Address - Phone:773-627-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.033509122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program