Healthcare Provider Details

I. General information

NPI: 1598405722
Provider Name (Legal Business Name): TARICA RASHAUN JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 EVELYN AVE APT 3
LOVES PARK IL
61111-5097
US

IV. Provider business mailing address

228 EVELYN AVE APT 3
LOVES PARK IL
61111-5097
US

V. Phone/Fax

Practice location:
  • Phone: 779-220-0223
  • Fax: 888-668-1804
Mailing address:
  • Phone: 779-220-0223
  • Fax: 888-668-1804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.024421
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: