Healthcare Provider Details

I. General information

NPI: 1790270049
Provider Name (Legal Business Name): LEEANN G JACKSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 GREEN BAY RD STE 2
KENOSHA WI
53142-2967
US

IV. Provider business mailing address

6525 GREEN BAY RD STE 2
KENOSHA WI
53142-2967
US

V. Phone/Fax

Practice location:
  • Phone: 262-999-3495
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7126-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16281-131
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number121-36
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178009221
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: