Provider Demographics
NPI:1538673116
Name:NEWBERRY, JACKSON I III
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:I
Last Name:NEWBERRY
Suffix:III
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 1:3750 MERRIMAC LN W
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-6258
Mailing Address - Country:US
Mailing Address - Phone:630-267-2885
Mailing Address - Fax:
Practice Address - Street 1:201 E PARK ST STE B
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1973
Practice Address - Country:US
Practice Address - Phone:847-262-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-19
Last Update Date:2017-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor