Provider Demographics
NPI:1366957342
Name:JACKSON, ROGER DALE (MA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 E 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE STATION
Mailing Address - State:IN
Mailing Address - Zip Code:46405-2966
Mailing Address - Country:US
Mailing Address - Phone:219-743-6579
Mailing Address - Fax:
Practice Address - Street 1:8200 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6227
Practice Address - Country:US
Practice Address - Phone:219-791-1400
Practice Address - Fax:219-791-1422
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health