Provider Demographics
NPI:1316054166
Name:JACKSON, AMY KATHLEEN (ATC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KATHLEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 170TH ST
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1451
Mailing Address - Country:US
Mailing Address - Phone:708-335-1415
Mailing Address - Fax:
Practice Address - Street 1:1816 170TH ST
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1451
Practice Address - Country:US
Practice Address - Phone:708-335-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer