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General NPI Number Information
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NPI Number | 1104178649
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Entity Type | Individual
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Provider Name | MR. KURT H JACKSON
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Gender | Male
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Dates
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Enumeration Date | 10/08/2012
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Last Update Date | 10/09/2024
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Provider Practice Location Address
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Address Line | 8044 S RACINE AVE
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City | CHICAGO
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State | IL
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Zip | 60620-3011
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Country | US
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Telephone | 773-723-9291
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Fax | 773-723-9291
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Provider Business Mailing Address
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Address Line | 2922 CHAYES PARK DR
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City | HOMEWOOD
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State | IL
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Zip | 60430-2907
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Country | US
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Telephone | 708-289-0203
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Fax | 773-723-9291
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178006138
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180015933
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License Number State | IL
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