MEDICARE: MS. JENNIFER LEE JACKSON MA, LCPC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	180014068	IL

General Provider Information

NPI Number	:	1134698723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER LEE JACKSON MA, LCPC.

Provider Business Mailing Address
First Line	:	15217 LOTUS DR
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-1915
Country	:	US
Telephone Number	:	216-956-3767
Fax Number	:

Provider Business Practice Location Address
First Line	:	636 CHURCH ST STE 415
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-4580
Country	:	US
Telephone Number	:	773-234-0194
Fax Number	:	773-676-0111

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2018
Last Update Date	:	12/14/2021

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