MEDICARE: DR. KENNETH JACKSON PH.D.

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	103TC0700X	Clinical Psychologist	071007090	IL
2	103TH0100X	Health Service Psychologist	20042218A	IN

General Provider Information

NPI Number	:	1588762108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH JACKSON PH.D.

Provider Business Mailing Address
First Line	:	5701 N ASHLAND AVE
Second Line	:	SUITE 205-A
City	:	CHICAGO
State	:	IL
Zip	:	60660-4027
Country	:	US
Telephone Number	:	773-454-7202
Fax Number	:	773-465-5041

Provider Business Practice Location Address
First Line	:	5701 N ASHLAND AVE
Second Line	:	SUITE 205-A
City	:	CHICAGO
State	:	IL
Zip	:	60660-4027
Country	:	US
Telephone Number	:	773-454-7202
Fax Number	:	773-465-5041

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	11/04/2010

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