Provider Demographics
NPI:1710754940
Name:JACKSON, MARCUS
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7312 N GREENVIEW AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2451
Mailing Address - Country:US
Mailing Address - Phone:517-219-7776
Mailing Address - Fax:
Practice Address - Street 1:1638 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3602
Practice Address - Country:US
Practice Address - Phone:866-815-6592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst