Provider Demographics
NPI:1225316581
Name:JACKSON, SHANA ONIELLA (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:ONIELLA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-3814
Mailing Address - Country:US
Mailing Address - Phone:312-752-7892
Mailing Address - Fax:855-783-9301
Practice Address - Street 1:2820 W 84TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-3814
Practice Address - Country:US
Practice Address - Phone:312-752-7892
Practice Address - Fax:855-783-9301
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA942691041C0700X
FLSW168381041C0700X
MI68011078931041C0700X
IL1490207341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health