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General NPI Number Information
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NPI Number | 1164080693
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Entity Type | Organization
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Legal Business Name | JACKSON THERAPY
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Dates
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Enumeration Date | 05/30/2019
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Last Update Date | 03/30/2023
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Provider Practice Location Address
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Address Line | 404 W GREEN ST
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City | URBANA
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State | IL
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Zip | 61801-3267
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Country | US
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Telephone | 217-706-5498
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Fax | 217-706-5779
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Provider Business Mailing Address
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Address Line | 230 W MAIN ST
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City | DECATUR
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State | IL
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Zip | 62523-1215
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Country | US
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Telephone | 217-706-5498
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Fax |
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Authorized Official
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Title or Position | OWNER/LEAD THERAPIST
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Name | ANGELA JACKSON
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Credential | LCSW
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Telephone | 217-840-4090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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