Provider Demographics
NPI:1588164958
Name:JACKSON, IRIS YVONNE
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:YVONNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4244 S MICHIGAN AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3150
Mailing Address - Country:US
Mailing Address - Phone:773-905-9175
Mailing Address - Fax:
Practice Address - Street 1:332 S MICHIGAN AVE STE 1024
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-4483
Practice Address - Country:US
Practice Address - Phone:888-726-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178013694101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional