Provider Demographics
NPI:1265761324
Name:JACKSON, CATHY GAIL (LCPC)
Entity type:Individual
Prefix:MS
First Name:CATHY
Middle Name:GAIL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 RIDGE RD
Mailing Address - Street 2:SUIOTE 200
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1760
Mailing Address - Country:US
Mailing Address - Phone:708-966-6091
Mailing Address - Fax:
Practice Address - Street 1:1820 RIDGE RD
Practice Address - Street 2:SUIOTE 200
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1760
Practice Address - Country:US
Practice Address - Phone:708-966-6091
Practice Address - Fax:708-585-6222
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006774101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474549320Medicaid