Healthcare Provider Details

I. General information

NPI: 1114607744
Provider Name (Legal Business Name): JACKIE ZAKARIJA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 ECLIPSE CTR
BELOIT WI
53511-3550
US

IV. Provider business mailing address

11501 ABERDEEN RD
BELVIDERE IL
61008-8702
US

V. Phone/Fax

Practice location:
  • Phone: 608-361-0311
  • Fax: 608-361-0312
Mailing address:
  • Phone: 815-540-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: