Provider Demographics
NPI:1912772146
Name:LOOP, JACKSON ELLIOT
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:ELLIOT
Last Name:LOOP
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 1:1215 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2116
Mailing Address - Country:US
Mailing Address - Phone:847-257-5640
Mailing Address - Fax:
Practice Address - Street 1:1215 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2116
Practice Address - Country:US
Practice Address - Phone:847-257-5640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst