Provider Demographics
NPI:1154529964
Name:JACKSON, RAUSHANAH (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:RAUSHANAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N MICHIGAN AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3959
Mailing Address - Country:US
Mailing Address - Phone:312-985-6195
Mailing Address - Fax:
Practice Address - Street 1:444 N MICHIGAN AVE STE 1200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3959
Practice Address - Country:US
Practice Address - Phone:312-985-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT47896106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN