Healthcare Provider Details

I. General information

NPI: 1427394485
Provider Name (Legal Business Name): MARIAN A JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2012
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N RUBY LN
FAIRVIEW HEIGHTS IL
62208-1926
US

IV. Provider business mailing address

125 N RUBY LN
FAIRVIEW HEIGHTS IL
62208-1926
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-4226
  • Fax: 618-398-1759
Mailing address:
  • Phone: 618-398-4226
  • Fax: 618-398-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.015627
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: