Provider Demographics
NPI:1639530215
Name:JACKSON, CORBY RYAN
Entity type:Individual
Prefix:
First Name:CORBY
Middle Name:RYAN
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 1:1225 RICHARDS ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60433-2745
Mailing Address - Country:US
Mailing Address - Phone:708-768-2144
Mailing Address - Fax:
Practice Address - Street 1:11300 N CENTRAL EXPY STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-6712
Practice Address - Country:US
Practice Address - Phone:844-824-8775
Practice Address - Fax:281-648-2200
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015589101YP2500X
TX95036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional