Provider Demographics
NPI:1275599367
Name:JACKSON, THERESA (MSW, LSW)
Entity Type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 N HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-1512
Mailing Address - Country:US
Mailing Address - Phone:708-449-3242
Mailing Address - Fax:
Practice Address - Street 1:715 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1422
Practice Address - Country:US
Practice Address - Phone:708-386-8145
Practice Address - Fax:708-848-6176
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker