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General NPI Number Information
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NPI Number | 1528480282
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Entity Type | Individual
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Provider Name | MICHAEL JACKSA LCPC
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Gender | Male
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Dates
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Enumeration Date | 01/15/2014
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Last Update Date | 01/15/2014
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Provider Practice Location Address
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Address Line | 1150 ESSINGTON RD SUITE 101
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City | JOLIET
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State | IL
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Zip | 60435-8447
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Country | US
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Telephone | 815-823-8460
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Fax | 815-823-8461
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Provider Business Mailing Address
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Address Line | 1150 ESSINGTON RD SUITE 101
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City | JOLIET
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State | IL
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Zip | 60435-8447
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Country | US
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Telephone | 815-823-8460
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Fax | 815-823-8461
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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 | 180.007598
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License Number State | IL
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