Active NPI
Donna Marie Jackson, MSW, LSW, CDP
- Social Worker
- Gurnee, IL
National Provider Identifier
1417495383
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Social Worker
- License
- 150-006550
- Practice address
- 4212 Old Grand Ave
Suite 102
Gurnee, IL 60031-2708 - Phone
- (847) 336-5621
- Fax
- (847) 336-2594
- NPI assigned
- Feb 10, 2017
- Last updated
- Feb 10, 2017
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Social Worker | 104100000X | 150-006550 | IL | Primary |
Addresses
Primary practice location
4212 Old Grand Ave
Suite 102
Gurnee, IL 60031-2708
Mailing address
860 Breeze Dr
Lake Villa, IL 60046-6692
Phone (847) 553-1259
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 150-006550 | IL | MD | Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Gurnee Counseling Center | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Mental Health Counselor
- Gurnee, IL
- NPI 1871624619
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1486684800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1486684800000",
"number": "1417495383",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "860 BREEZE DR",
"city": "LAKE VILLA",
"state": "IL",
"postal_code": "600466692",
"telephone_number": "847-553-1259"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4212 OLD GRAND AVE",
"address_2": "SUITE 102",
"city": "GURNEE",
"state": "IL",
"postal_code": "600312708",
"telephone_number": "847-336-5621",
"fax_number": "847-336-2594"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "DONNA",
"middle_name": "MARIE",
"name_prefix": "Mrs.",
"credential": "MSW, LSW, CDP",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2017-02-10",
"last_updated": "2017-02-10",
"status": "A"
},
"taxonomies": [
{
"code": "104100000X",
"taxonomy_group": "",
"desc": "Social Worker",
"state": "IL",
"license": "150-006550",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Gurnee, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.