Individual
DR. KENNETH JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
5701 N ASHLAND AVE, SUITE 205-A, CHICAGO, IL 60660-4027
(773) 454-7202
(773) 465-5041
Mailing address
5701 N ASHLAND AVE, SUITE 205-A, CHICAGO, IL 60660-4027
(773) 454-7202
(773) 465-5041
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
071007090
IL
103TH0100X
Health Service Psychologist
20042218A
IN
Other
Enumeration date
09/20/2006
Last updated
11/04/2010
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