Provider Demographics
NPI:1063046498
Name:JACKSON BEHAVIORAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:JACKSON BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADDISON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW
Authorized Official - Phone:708-983-8074
Mailing Address - Street 1:4137 SAUK TRL STE 146
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4137 SAUK TRL STE 146
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1253
Practice Address - Country:US
Practice Address - Phone:708-983-8074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty