Healthcare Provider Details

I. General information

NPI: 1285571109
Provider Name (Legal Business Name): STACY JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N COLUMBUS DR APT 1309
CHICAGO IL
60601-7947
US

IV. Provider business mailing address

222 N COLUMBUS DR APT 1309
CHICAGO IL
60601-7947
US

V. Phone/Fax

Practice location:
  • Phone: 312-415-1982
  • Fax: 312-415-1982
Mailing address:
  • Phone: 312-415-1982
  • Fax: 312-415-1982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.012279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: