Provider Demographics
NPI:1538946702
Name:JACKSON-LUCAS, ONTONIO
Entity type:Individual
Prefix:
First Name:ONTONIO
Middle Name:
Last Name:JACKSON-LUCAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 E GLENWOOD DYER RD
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-2227
Mailing Address - Country:US
Mailing Address - Phone:708-983-9044
Mailing Address - Fax:
Practice Address - Street 1:626 E GLENWOOD DYER RD
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-2227
Practice Address - Country:US
Practice Address - Phone:708-983-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1114421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical