Provider Demographics
NPI:1356214084
Name:SOUTHERN ILLINOIS COUNSELING PLLC
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:618-924-5633
Mailing Address - Street 1:608 S FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2525
Mailing Address - Country:US
Mailing Address - Phone:618-924-5633
Mailing Address - Fax:
Practice Address - Street 1:608 S FOREST AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2525
Practice Address - Country:US
Practice Address - Phone:618-924-5633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)