Provider Demographics
NPI:1548055239
Name:JACKSON, DEANNA
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 N PEORIA ST APT 2101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2368
Mailing Address - Country:US
Mailing Address - Phone:708-545-7415
Mailing Address - Fax:
Practice Address - Street 1:164 N PEORIA ST APT 2101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2368
Practice Address - Country:US
Practice Address - Phone:708-545-7415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-12
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209032018363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health