Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 036095105 | IL |
NPI | 1053419119 |
---|---|
Provider Name | Dr. Alyce F Jackson |
First Address | Kankakee, IL 60901-3493 |
Second Address | Kankakee, IL 60901-3493 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 22/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
36095105 | (05) | IL |
632039 | BC GROUP ID# (01) | IL |
G53877 | (02) | IL |