Healthcare Provider Details

I. General information

NPI: 1700915915
Provider Name (Legal Business Name): LAKECIA JACKSON-ROOKS OTRL, D.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8616 S NORMAL AVE
CHICAGO IL
60620-2153
US

IV. Provider business mailing address

8616 S NORMAL AVE
CHICAGO IL
60620-2153
US

V. Phone/Fax

Practice location:
  • Phone: 773-593-2396
  • Fax:
Mailing address:
  • Phone: 773-602-1725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056003991
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: