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General NPI Number Information
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NPI Number | 1821648668
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Entity Type | Individual
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Provider Name | ADDISON JACKSON JR. LCSW
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Gender | Male
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Dates
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Enumeration Date | 09/13/2019
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Last Update Date | 03/09/2023
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Provider Practice Location Address
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Address Line | 4137 SAUK TRL STE 146
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City | RICHTON PARK
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State | IL
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Zip | 60471-1253
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Country | US
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Telephone | 708-983-8074
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Fax |
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Provider Business Mailing Address
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Address Line | 3715 VILLAGE DR
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City | HAZEL CREST
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State | IL
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Zip | 60429-2444
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Country | US
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Telephone | 708-983-8074
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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 | 149.021059
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License Number State | IL
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