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General NPI Number Information
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NPI Number | 1114864188
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Entity Type | Individual
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Provider Name | KETAJIA JACKSON LPC
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Gender | Female
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Dates
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Enumeration Date | 04/29/2026
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Last Update Date | 04/29/2026
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Provider Practice Location Address
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Address Line | 3605 W FILLMORE ST
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City | CHICAGO
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State | IL
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Zip | 60624-4310
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Country | US
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Telephone | 773-588-0180
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Fax |
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Provider Business Mailing Address
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Address Line | 4213 S WELLS ST APT 2
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City | CHICAGO
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State | IL
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Zip | 60609-2813
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Country | US
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Telephone | 773-679-8324
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 178018536
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License Number State | IL
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