Provider Demographics
NPI:1417495383
Name:JACKSON, DONNA MARIE (MSW, LSW, CDP)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LSW, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6692
Mailing Address - Country:US
Mailing Address - Phone:847-553-1259
Mailing Address - Fax:
Practice Address - Street 1:4212 OLD GRAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2708
Practice Address - Country:US
Practice Address - Phone:847-336-5621
Practice Address - Fax:847-336-2594
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150-006550104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker