MEDICARE: DR. JACKSON NEWSOME PSYD

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	071010649	IL

General Provider Information

NPI Number	:	1740944438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACKSON NEWSOME PSYD

Provider Business Mailing Address
First Line	:	1331 N BOSWORTH AVE APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-3421
Country	:	US
Telephone Number	:	773-683-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1331 N BOSWORTH AVE APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-3421
Country	:	US
Telephone Number	:	773-683-3200
Fax Number	:

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

Provider Enumeration Date	:	10/28/2021
Last Update Date	:	10/12/2023

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