Provider Demographics
NPI:1003006842
Name:JACKSON, DEBORAH LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 W. PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-293-8437
Mailing Address - Fax:773-728-4751
Practice Address - Street 1:2820 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3803
Practice Address - Country:US
Practice Address - Phone:773-293-8437
Practice Address - Fax:773-728-4751
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical