Provider Demographics
NPI:1841875465
Name:JACKSON, MALINDA (LPC, CRC)
Entity type:Individual
Prefix:
First Name:MALINDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 WESTVIEW LN
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3705
Mailing Address - Country:US
Mailing Address - Phone:224-944-9533
Mailing Address - Fax:
Practice Address - Street 1:330 W TERRA COTTA AVE STE 4
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3552
Practice Address - Country:US
Practice Address - Phone:224-944-9533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178008315101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional