MEDICARE: JOHN L JACKSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071003528	IL

General Provider Information

NPI Number	:	1316169279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN L JACKSON PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 1718
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-0718
Country	:	US
Telephone Number	:	224-935-9807
Fax Number	:	888-656-4903

Provider Business Practice Location Address
First Line	:	PO BOX 1718
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-0718
Country	:	US
Telephone Number	:	224-935-9807
Fax Number	:	888-656-4903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	01/28/2025

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