Provider Demographics
NPI:1174848352
Name:JACKSON, MAUDETTE M
Entity Type:Individual
Prefix:DR
First Name:MAUDETTE
Middle Name:M
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 1:7725 S CRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-4118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 N DEARBORN ST
Practice Address - Street 2:SUITE 1012
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3300
Practice Address - Country:US
Practice Address - Phone:312-375-5621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006174103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical