Provider Demographics
NPI:1669829180
Name:JACKSON, AMARI (LCPC)
Entity Type:Individual
Prefix:
First Name:AMARI
Middle Name:
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 1:1136 S DELANO CT W STE B201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3734
Mailing Address - Country:US
Mailing Address - Phone:708-609-5274
Mailing Address - Fax:
Practice Address - Street 1:10009 S VAN VLISSINGEN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-5258
Practice Address - Country:US
Practice Address - Phone:708-527-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011861101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor