Provider Demographics
NPI:1447817028
Name:JACKSON, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:JACKSON
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 1:564 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-3672
Mailing Address - Country:US
Mailing Address - Phone:847-346-2236
Mailing Address - Fax:
Practice Address - Street 1:73 S RIVERSIDE DR FL 3
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-6452
Practice Address - Country:US
Practice Address - Phone:847-243-6458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
149.0230041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical