Active NPI
Reynaldo Jackson, DMD
- General Practice Dentistry
- Chicago, IL
National Provider Identifier
1407435696
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 019.036510
- Practice address
- 9521 S Western Ave
Chicago, IL 60643-1013 - Phone
- (773) 344-9120
- NPI assigned
- Apr 5, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DE61346798 | WA | |
| General Practice Dentistry | 1223G0001X | 019.036510 | IL | Primary |
Addresses
Primary practice location
9521 S Western Ave
Chicago, IL 60643-1013
Mailing address
10510 Gravelly Lake Dr SW
Lakewood, WA 98499-5036
Phone (253) 589-7030
Other practice location 1
10510 Gravelly Lake Dr SW
Lakewood, WA 98499-5036
Phone (253) 589-7030
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | Laptop | Health Information Exchange (HIE) |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019.036510 | IL | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1617580800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1757635200000",
"number": "1407435696",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10510 GRAVELLY LAKE DR SW",
"city": "LAKEWOOD",
"state": "WA",
"postal_code": "984995036",
"telephone_number": "253-589-7030"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9521 S WESTERN AVE",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606431013",
"telephone_number": "773-344-9120"
}
],
"practiceLocations": [
{
"address_1": "10510 Gravelly Lake Dr SW",
"address_purpose": "LOCATION",
"city": "Lakewood",
"state": "WA",
"postal_code": "984995036",
"country_code": "US",
"telephone_number": "253-589-7030",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "JACKSON",
"first_name": "REYNALDO",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-04-05",
"last_updated": "2025-09-12",
"certification_date": "2025-09-12",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WA",
"license": "DE61346798",
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "IL",
"license": "019.036510",
"primary": true
}
],
"identifiers": [],
"endpoints": [
{
"endpointType": "CONNECT",
"endpointTypeDescription": "CONNECT URL",
"endpoint": "Laptop",
"affiliation": "N",
"use": "HIE",
"useDescription": "Health Information Exchange (HIE)",
"address_1": "111 E 210th St",
"city": "Bronx",
"state": "NY",
"country_code": "US",
"postal_code": "104672401",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 12, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.