Individual
MR. GLENN JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LSW, LCPC, CMH
Contact information
Practice address
504 MICAH DR, DRAWER M, OLNEY, IL 62450-4720
(618) 395-4309
(618) 395-4507
Mailing address
504 MICAH DR, DRAWER M, OLNEY, IL 62450-4720
(618) 395-4309
(618) 395-4507
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YM0800X
Mental Health Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
180.000994
LICENSED CLINICAL PROFESSIONAL COUNSELOR
IL
Enumeration date
10/08/2015
Last updated
10/08/2015
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