Provider Demographics
NPI:1619400942
Name:JACKSON, CELESTE ASHLEY (PHD)
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:ASHLEY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CONCORD DR S
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-6026
Mailing Address - Country:US
Mailing Address - Phone:773-289-8755
Mailing Address - Fax:
Practice Address - Street 1:155 CONCORD DR S
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-6026
Practice Address - Country:US
Practice Address - Phone:773-289-8755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178012452101YM0800X
IL180.015650101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health