Provider Demographics
NPI:1801969233
Name:JACKMAN, ROBERT A JR (M S LCPC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:JACKMAN
Suffix:JR
Gender:M
Credentials:M S LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N 2ND ST STE 304
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1853
Mailing Address - Country:US
Mailing Address - Phone:630-721-5765
Mailing Address - Fax:630-377-0886
Practice Address - Street 1:311 N 2ND ST STE 304
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1853
Practice Address - Country:US
Practice Address - Phone:630-721-5765
Practice Address - Fax:630-377-0886
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional