Provider Demographics
NPI:1073138194
Name:JACKSON, KELLYN (LPC, R-DMT)
Entity Type:Individual
Prefix:
First Name:KELLYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 N SHERIDAN RD APT 3A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2059
Mailing Address - Country:US
Mailing Address - Phone:847-624-5298
Mailing Address - Fax:
Practice Address - Street 1:2835 N SHEFFIELD AVE STE 304
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5084
Practice Address - Country:US
Practice Address - Phone:630-866-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILR-DMT-2538225600000X
IL178016509101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619493855OtherPRIVATE INSURANCE