Provider Demographics
NPI:1285811273
Name:JACKSON, CHERYL LYNN (RDCS)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RDCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20039 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-1397
Mailing Address - Country:US
Mailing Address - Phone:708-479-0271
Mailing Address - Fax:708-479-4425
Practice Address - Street 1:20039 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-1397
Practice Address - Country:US
Practice Address - Phone:708-479-0271
Practice Address - Fax:708-479-4425
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL48673246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201010Medicare PIN