Healthcare Provider Details

I. General information

NPI: 1073138194
Provider Name (Legal Business Name): KELLYN JACKSON LPC, R-DMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N SHEFFIELD AVE STE 304
CHICAGO IL
60657-5084
US

IV. Provider business mailing address

7400 N SHERIDAN RD APT 3A
CHICAGO IL
60626-2059
US

V. Phone/Fax

Practice location:
  • Phone: 630-866-5666
  • Fax:
Mailing address:
  • Phone: 847-624-5298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License NumberR-DMT-2538
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178016509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: