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General NPI Number Information
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NPI Number | 1437456522
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Entity Type | Individual
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Provider Name | MARY ELISABETH JACKSON LCPC
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Gender | Female
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Dates
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Enumeration Date | 02/25/2011
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Last Update Date | 02/25/2011
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Provider Practice Location Address
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Address Line | 804 SOUTH OAKLAND AVE
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City | CARBONDALE
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State | IN
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Zip | 62901
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Country | US
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Telephone | 618-203-3975
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Fax | 618-529-2182
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Provider Business Mailing Address
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Address Line | 804 S OAKLAND AVE
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City | CARBONDALE
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State | IL
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Zip | 62901-2555
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Country | US
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Telephone | 618-203-3975
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Fax | 618-529-2182
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 180.007729
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License Number State | IL
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