Provider Demographics
NPI:1043830680
Name:JACKSON, KERI ALYSE
Entity Type:Individual
Prefix:MRS
First Name:KERI
Middle Name:ALYSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 GRASS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8799
Mailing Address - Country:US
Mailing Address - Phone:708-369-9062
Mailing Address - Fax:
Practice Address - Street 1:3411 GRASS LAKE DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8799
Practice Address - Country:US
Practice Address - Phone:708-369-9062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst