Provider Demographics
NPI:1548972276
Name:JACKSON, TAMICA D (LCPC)
Entity type:Individual
Prefix:
First Name:TAMICA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 N LECLAIRE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3030
Mailing Address - Country:US
Mailing Address - Phone:916-719-7193
Mailing Address - Fax:
Practice Address - Street 1:1117 N LECLAIRE AVE APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3030
Practice Address - Country:US
Practice Address - Phone:916-719-7193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013845101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health