Healthcare Provider Details

I. General information

NPI: 1447817028
Provider Name (Legal Business Name): ROBERT JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 S RIVERSIDE DR FL 3
ELGIN IL
60120-6452
US

IV. Provider business mailing address

564 DOUGLAS AVE
ELGIN IL
60120-3672
US

V. Phone/Fax

Practice location:
  • Phone: 847-243-6458
  • Fax:
Mailing address:
  • Phone: 847-346-2236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.023004
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: