=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447817028
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT JACKSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2019
-----------------------------------------------------
Last Update Date | 11/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 73 S RIVERSIDE DR FL 3
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60120-6452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-243-6458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 564 DOUGLAS AVE
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60120-3672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-346-2236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.023004
-----------------------------------------------------
License Number State |
-----------------------------------------------------