Provider Demographics
NPI:1568833283
Name:JACKSON, GLENN (LSW, LCPC, CMH)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LSW, LCPC, CMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 MICAH DR
Mailing Address - Street 2:DRAWER M
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-4720
Mailing Address - Country:US
Mailing Address - Phone:618-395-4309
Mailing Address - Fax:618-395-4507
Practice Address - Street 1:504 MICAH DR
Practice Address - Street 2:DRAWER M
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-4720
Practice Address - Country:US
Practice Address - Phone:618-395-4309
Practice Address - Fax:618-395-4507
Is Sole Proprietor?:No
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.000994OtherLICENSED CLINICAL PROFESSIONAL COUNSELOR