Active NPI
Gabrielle Elyse Jackson
- Physical Therapy Assistant
- Sullivan, IL
National Provider Identifier
1982333472
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 160.007936
- Practice address
- 1 Masonic Way
Sullivan, IL 61951-9467 - Phone
- (217) 728-3700
- NPI assigned
- Jun 9, 2022
- Last updated
- Jun 9, 2022
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 160.007936 | IL | Primary |
Addresses
Primary practice location
1 Masonic Way
Sullivan, IL 61951-9467
Mailing address
2128 E 1525 North Rd
Shelbyville, IL 62565-4537
Phone (217) 273-7930
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 160.007936 | IL | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1654732800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1654732800000",
"number": "1982333472",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2128 E 1525 NORTH RD",
"city": "SHELBYVILLE",
"state": "IL",
"postal_code": "625654537",
"telephone_number": "217-273-7930"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1 MASONIC WAY",
"city": "SULLIVAN",
"state": "IL",
"postal_code": "619519467",
"telephone_number": "217-728-3700"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "GABRIELLE",
"middle_name": "ELYSE",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2022-06-09",
"last_updated": "2022-06-09",
"certification_date": "2022-06-09",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "IL",
"license": "160.007936",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Sullivan, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.