Healthcare Provider Details

I. General information

NPI: 1679047450
Provider Name (Legal Business Name): SHANEL JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W JACKSON BLVD STE 1700
CHICAGO IL
60604-3597
US

IV. Provider business mailing address

7335 HOLLY CT APT 2
RIVER FOREST IL
60305-1969
US

V. Phone/Fax

Practice location:
  • Phone: 646-941-7645
  • Fax:
Mailing address:
  • Phone: 510-393-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180016978
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: