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General NPI Number Information
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NPI Number | 1457740821
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Entity Type | Individual
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Provider Name | BRIANNE AR JACKSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 01/22/2015
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Last Update Date | 01/01/2025
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Provider Practice Location Address
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Address Line | 1880 N STATE ROUTE 50 # C
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City | BOURBONNAIS
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State | IL
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Zip | 60914-4432
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Country | US
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Telephone | 815-641-9630
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Fax |
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Provider Business Mailing Address
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Address Line | 114 MEADOWS CT
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City | BOURBONNAIS
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State | IL
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Zip | 60914-1120
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Country | US
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Telephone | 815-641-9630
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.019017
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License Number State | IL
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