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General NPI Number Information
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NPI Number | 1730231135
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Entity Type | Organization
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Legal Business Name | SPRINGFIELD CTR PSYCHOLOGICAL SVS
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1201 S VETERANS PKWY SUITE B
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City | SPRINGFIELD
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State | IL
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Zip | 62704-6321
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Country | US
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Telephone | 217-793-2770
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Fax | 217-793-2887
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Provider Business Mailing Address
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Address Line | 1201 S VETERANS PKWY SUITE B
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City | SPRINGFIELD
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State | IL
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Zip | 62704-6321
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Country | US
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Telephone | 217-793-2770
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Fax | 217-793-2887
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Authorized Official
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Title or Position | PSYCHOLOGIST PRESIDENT
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Name | DR. ROBERT LEON JACKSON
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Credential | PHD
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Telephone | 217-793-2770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State | IL
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