Provider Demographics
NPI:1649574260
Name:GOLDEN-JACKSON, LORETTA R
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:R
Last Name:GOLDEN-JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16278 PRINCE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3233
Mailing Address - Country:US
Mailing Address - Phone:708-754-8815
Mailing Address - Fax:
Practice Address - Street 1:73 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1414
Practice Address - Country:US
Practice Address - Phone:708-754-8815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst