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Individual
KELLYN JACKSON
Active
Individual
KELLYN JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPC, R-DMT
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
178016509
IL
225600000X
Dance Therapist
R-DMT-2538
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1619493855
PRIVATE INSURANCE
IL
Enumeration date
06/15/2020
Last updated
10/04/2022
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