Provider Demographics
NPI:1871825984
Name:JACKSON, FAY E (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:FAY
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 W ROUTE 64
Mailing Address - Street 2:
Mailing Address - City:ST. CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175
Mailing Address - Country:US
Mailing Address - Phone:630-587-5631
Mailing Address - Fax:
Practice Address - Street 1:3140 W ROUTE 64
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175
Practice Address - Country:US
Practice Address - Phone:630-587-5631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14095101YA0400X
IL149-0103741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)