1134698723 NPI number — MS. JENNIFER LEE JACKSON MA, LCPC.

Table of content: DR. STAVONNIE PATTERSON M.D. (NPI 1710021100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134698723 NPI number — MS. JENNIFER LEE JACKSON MA, LCPC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
JENNIFER
Provider Middle Name:
LEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA, LCPC.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134698723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15217 LOTUS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44128-1915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-956-3767
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
636 CHURCH ST STE 415
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60201-4580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-234-0194
Provider Business Practice Location Address Fax Number:
773-676-0111
Provider Enumeration Date:
11/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  180014068 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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