Provider Demographics
NPI:1790036846
Name:JACKSON, JILL CHRISTINE (MA, LCPC)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:CHRISTINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3838
Mailing Address - Country:US
Mailing Address - Phone:217-744-3525
Mailing Address - Fax:217-744-3535
Practice Address - Street 1:215 S GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3838
Practice Address - Country:US
Practice Address - Phone:217-744-3525
Practice Address - Fax:217-744-3535
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2015-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional