Provider Demographics
NPI:1013530104
Name:JACKSON, REGINALD P
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:P
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 1:1524 SHIRLEY DR STE 2008
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-6213
Mailing Address - Country:US
Mailing Address - Phone:708-288-4033
Mailing Address - Fax:
Practice Address - Street 1:4081 SOUTHWICK DRIVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-6044
Practice Address - Country:US
Practice Address - Phone:708-747-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker