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General NPI Number Information
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NPI Number | 1134698723
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Entity Type | Individual
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Provider Name | JENNIFER LEE JACKSON MA, LCPC.
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Gender | Female
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Dates
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Enumeration Date | 11/13/2018
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Last Update Date | 12/14/2021
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Provider Practice Location Address
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Address Line | 636 CHURCH ST STE 415
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City | EVANSTON
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State | IL
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Zip | 60201-4580
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Country | US
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Telephone | 773-234-0194
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Fax | 773-676-0111
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Provider Business Mailing Address
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Address Line | 15217 LOTUS DR
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City | CLEVELAND
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State | OH
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Zip | 44128-1915
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Country | US
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Telephone | 216-956-3767
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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 | 180014068
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License Number State | IL
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