Provider Demographics
NPI:1437456522
Name:JACKSON, MARY ELISABETH (LCPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELISABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 S OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2555
Mailing Address - Country:US
Mailing Address - Phone:618-203-3975
Mailing Address - Fax:618-529-2182
Practice Address - Street 1:804 SOUTH OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IN
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-203-3975
Practice Address - Fax:618-529-2182
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007729101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor