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General NPI Number Information
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NPI Number | 1710404496
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Entity Type | Individual
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Provider Name | TAWANN JACKSON ED.S, NCSP
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Gender | Female
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Dates
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Enumeration Date | 08/24/2017
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Last Update Date | 08/24/2017
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Provider Practice Location Address
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Address Line | 360 BLAIR LANE DOOR 13
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City | BOLINGBROOK
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State | IL
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Zip | 60615
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Country | US
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Telephone | 630-679-1210
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Fax |
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Provider Business Mailing Address
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Address Line | 360 BLAIR LANE DOOR 13
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City | BOLINGBROOK
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State | IL
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Zip | 60440
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Country | US
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Telephone | 630-679-1210
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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 | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 2403396
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License Number State | IL
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