Provider Demographics
NPI:1528414976
Name:JACKSON, KIYANA (LCPC)
Entity Type:Individual
Prefix:
First Name:KIYANA
Middle Name:
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 1:1651 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-4892
Mailing Address - Country:US
Mailing Address - Phone:708-997-1301
Mailing Address - Fax:
Practice Address - Street 1:1175 LILY CACHE LN
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-3122
Practice Address - Country:US
Practice Address - Phone:815-290-9048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional