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General NPI Number Information
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NPI Number | 1528414976
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Entity Type | Individual
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Provider Name | KIYANA JACKSON LCPC
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Gender | Female
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Dates
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Enumeration Date | 05/04/2016
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Last Update Date | 05/04/2016
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Provider Practice Location Address
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Address Line | 1175 LILY CACHE LN
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City | BOLINGBROOK
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State | IL
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Zip | 60490-3122
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Country | US
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Telephone | 815-290-9048
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Fax |
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Provider Business Mailing Address
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Address Line | 1651 ROSE LN
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City | ROMEOVILLE
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State | IL
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Zip | 60446-4892
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Country | US
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Telephone | 708-997-1301
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.009857
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License Number State | IL
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