Individual
FAY E JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW, CADC
Contact information
Practice address
3140 W ROUTE 64, ST. CHARLES, IL 60175
(630) 587-5631
Mailing address
3140 W ROUTE 64, ST. CHARLES, IL 60175
(630) 587-5631
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
14095
IL
1041C0700X
Clinical Social Worker
Primary
149-010374
IL
Other
Enumeration date
02/01/2010
Last updated
02/01/2010
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