Provider Demographics
NPI:1104098508
Name:JACKSON, GALE VICTORIA (NP)
Entity type:Individual
Prefix:MS
First Name:GALE
Middle Name:VICTORIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 PHINGSTEN ROAD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025
Mailing Address - Country:US
Mailing Address - Phone:847-657-5786
Mailing Address - Fax:
Practice Address - Street 1:1225 W MORSE AVE
Practice Address - Street 2:305
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-5798
Practice Address - Country:US
Practice Address - Phone:773-262-3062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care