DR. LARRY M. JACKSON (NPI# 1710068499) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1710068499 |
| Entity Type | Individual |
| Full Name | DR. LARRY M. JACKSON |
| Credential | D.N |
| Practice Address |
9357 S Kingston Ave Chicago IL 60617-4042 |
| Practice Telephone | 7739785554 |
| Practice Fax Number | 7739785802 |
| Mailing Telephone | 7739785554 |
| Mailing Fax Number | 7739785802 |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2007-07-08 |
| Gender Code | M |
| Is Sole Proprietor | Y |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| X | 133NN1002X |
Nutritionist Specialization: Nutrition, Education |
IL | Dietary & Nutritional Service Providers | |
| X | 174400000X | Specialist | IL | Other Service Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| IL | BCBS | 0001632277 | 01 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1568855724 | Larry Jackson Jr. | Specialist/Technologist | 826 Warfield Pl, Lexington, KY 40505-3612 | 2015-03-12 |
| 1396186276 | Larry Tyler Jackson | Dentist | 14100 N 83rd Ave, Ste 280, Peoria, AZ 85381-5658 | 2013-07-08 |
| 1093878191 | Larry Randolph Jackson | Registered Nurse | 615 Rapids Rd, Columbia, SC 29212-3024 | 2006-12-19 |
| 1093169062 | Larry Jackson Jr. | Counselor | 1420 Central Ave, Dubuque, IA 52001-4842 | 2016-04-15 |
| 1679971667 | Larry Jackson | Specialist | 1501 5th Ave N, St Petersburg, FL 33705-2008 | 2014-12-08 |
| 1578880548 | Larry Arthur Jackson | Family Medicine | 1445 Gateway Blvd, Cottage Grove, OR 97424-1224 | 2010-04-29 |
| 1023285582 | Larry Ronald Jackson II | Internal Medicine | 2301 Erwin Rd, Durham, NC 27710-0001 | 2008-05-14 |
| 1912928441 | Larry D Jackson | Personal Emergency Response Attendant | 500 Gypsy Ln, Youngstown, OH 44504-1315 | 2006-07-21 |
| 1275574295 | Larry K Jackson | Internal Medicine | 2660 10th Ave S, Suite 528, Birmingham, AL 35205-1605 | 2006-06-09 |
| 1720049349 | Larry Jackson | Family Medicine | 6565 W Main St, Kalamazoo, MI 49009-6114 | 2006-03-31 |
| Street Address |
9357 S KINGSTON AVE |
| City | CHICAGO |
| State | IL |
| Zip Code | 60617-4042 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1871102921 | Manuel Lule | Physical Therapy Assistant | 9535 S Jeffery Boulevard, Chicago, IL 60617 | 2020-07-24 |
| 1083253546 | Vanaja Thotten | Internal Medicine | 8012 S.crandon Ave, Chicago, IL 60617 | 2020-01-02 |
| 1427527365 | Stony Island Dental PC | Dentist | 1600 E 93rd Street, Chicago, IL 60617 | 2018-11-21 |
| 1871060301 | Tamika Nicole Whitehead | Social Worker | 2822 East 83rd Street, Chicago, IL 60617 | 2018-11-02 |
| 1528543774 | Felicia Nwankwo | Nurse Practitioner | 2822 E 83rd Street Bradond Famiy Health Cener, Chicago, IL 60617 | 2018-10-03 |
| 1972099307 | David Phan | Optometrist | 1753 E 95th St Ste B-100, Chicago, IL 60617 | 2018-07-09 |
| 1831607340 | Pamela Evette Ewing | Counselor | 9145 S. Merrill Ave, Chicago, IL 60617 | 2018-01-18 |
| 1366976631 | Ali Mostafa Serhal | Radiology | 240 E. Huron St, Suite 1-203, Chicago, IL 60617 | 2017-04-13 |
| 1447784921 | 1915-25 95th St., LLC | Clinic/Center | 1915 E 95th St, Chicago, IL 60617 | 2017-04-12 |
| 1881140408 | Yeferson Laverde | Social Worker | 3062 East 31st, Chicago, IL 60617 | 2016-09-01 |
| Find all providers in zip 60617 | ||||
| Taxonomy Code | 133NN1002X |
| Grouping | Dietary & Nutritional Service Providers |
| Classification | Nutritionist |
| Specialization | Nutrition, Education |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1881169027 | Nourishment Works PC | Nutritionist | 4633 N Western Ave Ste 202, Chicago, IL 60625-2181 | 2018-10-03 |
| 1093187239 | Preventive Cardiovascular Services & Health Services | Nutritionist | 4800 S Chicago Beach Dr Apt 311s, Chicago, IL 60615-7019 | 2015-10-27 |
| 1790067353 | Patricia Clay | Nutritionist | 6511 S Bell Ave, Chicago, IL 60636-2529 | 2011-09-09 |
| 1164745113 | Linda W Clarke | Nutritionist | 7406 S Oglesby Ave, Chicago, IL 60649-3312 | 2010-03-04 |
| 1275725244 | Vandana Puri | Nutritionist | 1130 S Michigan Ave, Apt 3103, Chicago, IL 60605-2521 | 2007-08-14 |
| 1497959845 | Regina E. Shelton | Nutritionist | 1531 S Saint Louis Ave, Chicago, IL 60623-2155 | 2007-06-11 |
| 1598773707 | Lynn Danford | Nutritionist | 4338 N Richmond St, Chicago, IL 60618-1406 | 2006-08-03 |
| 1588199293 | Loop Nutrition Inc | Nutritionist | 16 N Peoria St, Chicago, IL 60607-2609 | 2017-05-01 |
| 1306394416 | Move Therapy and Wellness 1241 LLC | Nutritionist | 3808 N Ashland Ave, Commercial Condo, Chicago, IL 60613-5382 | 2016-09-17 |
| 1689806358 | Fuller Health Group PC | Nutritionist | 211 N Clinton St, Suite 2s, Chicago, IL 60661-1282 | 2009-08-14 |
| Find all providers in CHICAGO | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.