Provider Demographics
NPI:1538674312
Name:JACKSON, CHRISTOPHER D (LPC)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9021 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6806
Mailing Address - Country:US
Mailing Address - Phone:262-220-8200
Mailing Address - Fax:
Practice Address - Street 1:9021 17TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6806
Practice Address - Country:US
Practice Address - Phone:262-220-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-03
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008376101YM0800X
WI6786-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health