Provider Demographics
NPI:1316980766
Name:JACKSON, LISA R (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22285 N PEPPER RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:LAKE BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2538
Mailing Address - Country:US
Mailing Address - Phone:847-882-6604
Mailing Address - Fax:847-882-6228
Practice Address - Street 1:22285 N PEPPER RD
Practice Address - Street 2:SUITE 401
Practice Address - City:LAKE BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2538
Practice Address - Country:US
Practice Address - Phone:847-882-6604
Practice Address - Fax:847-882-6228
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL309002626363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner