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

Table of content: MS. JENNIFER LEE JACKSON MA, LCPC. (NPI 1134698723)

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)





Copyright © 2007-2025 www.npivalidator.com