MEDICARE: SOUTHERN ILLINOIS COUNSELING PLLC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1356214084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN ILLINOIS COUNSELING PLLC

Provider Business Mailing Address
First Line	:	608 S FOREST AVE
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-2525
Country	:	US
Telephone Number	:	618-924-5633
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 S FOREST AVE
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-2525
Country	:	US
Telephone Number	:	618-924-5633
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ADAM JACKSON
Credential	:	LCPC
Telephone Number	:	618-924-5633

Provider Enumeration Date	:	09/29/2025
Last Update Date	:	04/07/2026

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