Provider Demographics
NPI:1710239090
Name:JACKSON, DYNEEN MARIE (MSW)
Entity Type:Individual
Prefix:
First Name:DYNEEN
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22810 EAST DR
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2312
Mailing Address - Country:US
Mailing Address - Phone:708-655-9303
Mailing Address - Fax:
Practice Address - Street 1:22810 EAST DR
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-2312
Practice Address - Country:US
Practice Address - Phone:708-655-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker