MEDICARE: IRIS YVONNE JACKSON

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	101YP2500X	Professional Counselor	178013694	IL

General Provider Information

NPI Number	:	1588164958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRIS YVONNE JACKSON

Provider Business Mailing Address
First Line	:	4244 S MICHIGAN AVE APT 3E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-3150
Country	:	US
Telephone Number	:	773-905-9175
Fax Number	:

Provider Business Practice Location Address
First Line	:	332 S MICHIGAN AVE STE 1024
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60604-4483
Country	:	US
Telephone Number	:	888-726-7170
Fax Number	:

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

Provider Enumeration Date	:	02/12/2018
Last Update Date	:	02/12/2018

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