Provider Demographics
NPI:1356175889
Name:JACKSON, BRIANNA (LPC)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18653 BERNADINE ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-3506
Mailing Address - Country:US
Mailing Address - Phone:708-822-3575
Mailing Address - Fax:
Practice Address - Street 1:7300 W COLLEGE DR STE 203
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1183
Practice Address - Country:US
Practice Address - Phone:708-488-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.020373101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor