MEDICARE: LEEANN G JACKSON LPC

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	7126-125	WI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	16281-131	WI
3	221700000X	Art Therapist	121-36	WI
4	101YP2500X	Professional Counselor	178009221	IL

General Provider Information

NPI Number	:	1790270049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEEANN G JACKSON LPC

Provider Business Mailing Address
First Line	:	6525 GREEN BAY RD STE 2
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-2967
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6525 GREEN BAY RD STE 2
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-2967
Country	:	US
Telephone Number	:	262-999-3495
Fax Number	:

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

Provider Enumeration Date	:	06/28/2018
Last Update Date	:	06/03/2026

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