Basic Information
| Provider Information | |||||||||
| NPI: | 1003006842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2820 W. PETERSON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732938437 | ||||||||
| FaxNumber: | 7737284751 | ||||||||
| Practice Location | |||||||||
| Address1: | 2820 W PETERSON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606593803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732938437 | ||||||||
| FaxNumber: | 7737284751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 07/27/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.