MEDICARE: MS. IDA B JACKSON 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	180-000225	IL

General Provider Information

NPI Number	:	1659682037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IDA B JACKSON LCPC,

Provider Business Mailing Address
First Line	:	4314 S COTTAGE GROVE AVE
Second Line	:	SUITE 208
City	:	CHICAGO
State	:	IL
Zip	:	60653-3514
Country	:	US
Telephone Number	:	312-747-0036
Fax Number	:	312-747-2208

Provider Business Practice Location Address
First Line	:	4314 S COTTAGE GROVE AVE
Second Line	:	SUITE 208
City	:	CHICAGO
State	:	IL
Zip	:	60653-3514
Country	:	US
Telephone Number	:	312-747-0036
Fax Number	:	312-747-2208

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

Provider Enumeration Date	:	06/30/2010
Last Update Date	:	06/30/2010

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