Provider Demographics
NPI:1497346696
Name:JACKSON, ADAM J
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 CHARLES RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5540
Mailing Address - Country:US
Mailing Address - Phone:618-924-5633
Mailing Address - Fax:
Practice Address - Street 1:209 W COMMERCIAL DR STE H
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-2057
Practice Address - Country:US
Practice Address - Phone:618-351-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-30
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health