Provider Demographics
NPI:1104178649
Name:JACKSON, KURT H
Entity Type:Individual
Prefix:MR
First Name:KURT
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 CHAYES PARK DR
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2907
Mailing Address - Country:US
Mailing Address - Phone:708-289-0203
Mailing Address - Fax:773-723-9291
Practice Address - Street 1:8044 S RACINE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-3011
Practice Address - Country:US
Practice Address - Phone:773-723-9291
Practice Address - Fax:773-723-9291
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178006138101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional