Provider Demographics
NPI:1932128865
Name:JACKSON, WILLIAM P (MSW, LCSW, ACSW)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW, LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 GRAND AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2321
Mailing Address - Country:US
Mailing Address - Phone:847-377-8086
Mailing Address - Fax:847-984-5682
Practice Address - Street 1:3010 GRAND AVE FL 1
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2321
Practice Address - Country:US
Practice Address - Phone:847-377-8086
Practice Address - Fax:847-984-5682
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0016361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-001636Medicaid
201725Medicare ID - Type Unspecified
ILR21035Medicare UPIN