Kellyn Jackson, LPC, R-DMT

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

178016509 Issued in IL

Practice address

2835 N Sheffield Ave Ste 304
Chicago, IL 60657-5084

Phone

(630) 866-5666

NPI assigned

Jun 15, 2020

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1592179200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664841600000",
    "number": "1073138194",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7400 N SHERIDAN RD APT 3A",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606262059",
            "telephone_number": "847-624-5298"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2835 N SHEFFIELD AVE STE 304",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606575084",
            "telephone_number": "630-866-5666"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2310 W Roosevelt Rd",
            "address_purpose": "LOCATION",
            "city": "Chicago",
            "state": "IL",
            "postal_code": "606081131",
            "country_code": "US",
            "telephone_number": "312-439-1552",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KELLYN",
        "credential": "LPC, R-DMT",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-06-15",
        "last_updated": "2022-10-04",
        "certification_date": "2022-10-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225600000X",
            "taxonomy_group": "",
            "desc": "Dance Therapist",
            "state": "IL",
            "license": "R-DMT-2538",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "178016509",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRIVATE INSURANCE",
            "identifier": "1619493855",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Joy Jackson
• Juanita Jackson, PHARMD
• Kaitlyn Nicole Jackson
• Karen Jackson, M.D.
• Katherine L Jackson
• Kendel Jackson
• Kenneth Jackson, PH.D.
• Ketajia Jackson, LPC
• Kiqiana Jackson
• Kristan Jackson, MS OTR/L

• Professional Counselor in Chicago, IL
• Providers in Chicago, IL by specialty
• Professional Counselor in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.