Individual
CORNELL DEMETRIUS JACKSON SR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MS MENTAL HEALTH
Contact information
Practice address
2615 EDWARDS ST, ALTON, IL 62002-3915
(730) 274-0085
Mailing address
2615 EDWARDS ST, ALTON, IL 62002-3915
(730) 274-0085
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Enumeration date
06/13/2022
Last updated
03/25/2026
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