Provider Demographics
NPI:1104462738
Name:JACKSON, NUSHA SYLAJ (FNP)
Entity type:Individual
Prefix:MRS
First Name:NUSHA
Middle Name:SYLAJ
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 W MADISON ST APT 307
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2657
Mailing Address - Country:US
Mailing Address - Phone:248-770-5168
Mailing Address - Fax:
Practice Address - Street 1:1656 N. WELLS
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3224
Practice Address - Country:US
Practice Address - Phone:312-643-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041434377163WP2201X
IL209.021965363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care