Provider Demographics
NPI:1134698723
Name:JACKSON, JENNIFER LEE (MA, LCPC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15217 LOTUS DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-1915
Mailing Address - Country:US
Mailing Address - Phone:216-956-3767
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 415
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4580
Practice Address - Country:US
Practice Address - Phone:773-234-0194
Practice Address - Fax:773-676-0111
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014068101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health