Provider Demographics
NPI:1598320749
Name:JACKSON, LAUREN MICHELLE (LCPC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
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 1:308 E 25TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-5500
Mailing Address - Country:US
Mailing Address - Phone:847-440-4330
Mailing Address - Fax:
Practice Address - Street 1:1136 S DELANO CT W APT 707
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3738
Practice Address - Country:US
Practice Address - Phone:847-440-4330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014672101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional