Provider Demographics
NPI:1659682037
Name:JACKSON, IDA B (LCPC,)
Entity Type:Individual
Prefix:MS
First Name:IDA
Middle Name:B
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 1:4314 S COTTAGE GROVE AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3514
Mailing Address - Country:US
Mailing Address - Phone:312-747-0036
Mailing Address - Fax:312-747-2208
Practice Address - Street 1:4314 S COTTAGE GROVE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3514
Practice Address - Country:US
Practice Address - Phone:312-747-0036
Practice Address - Fax:312-747-2208
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-000225101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health