Provider Demographics
NPI:1750076782
Name:HOLLWAY, JACKSON G (LPC, MA, NCC)
Entity type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:G
Last Name:HOLLWAY
Suffix:
Gender:M
Credentials:LPC, MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 SKOKIE BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-4033
Mailing Address - Country:US
Mailing Address - Phone:312-625-6241
Mailing Address - Fax:
Practice Address - Street 1:910 SKOKIE BLVD STE 215
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-4033
Practice Address - Country:US
Practice Address - Phone:312-625-6241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018510101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty