Active NPI
Glenn Jackson, LSW, LCPC, CMH
- Mental Health Counselor
- Olney, IL
National Provider Identifier
1568833283
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- Practice address
- 504 Micah Dr
Drawer M
Olney, IL 62450-4720 - Phone
- (618) 395-4309
- Fax
- (618) 395-4507
- NPI assigned
- Oct 8, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | |||
| Mental Health Counselor | 101YM0800X | Primary |
Addresses
Primary practice location
504 Micah Dr
Drawer M
Olney, IL 62450-4720
Mailing address
504 Micah Dr
Drawer M
Olney, IL 62450-4720
Phone (618) 395-4309
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 180.000994 | Other | IL | LICENSED CLINICAL PROFESSIONAL COUNSELOR |
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)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1444262400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1444262400000",
"number": "1568833283",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "504 MICAH DR",
"address_2": "DRAWER M",
"city": "OLNEY",
"state": "IL",
"postal_code": "624504720",
"telephone_number": "618-395-4309",
"fax_number": "618-395-4507"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "504 MICAH DR",
"address_2": "DRAWER M",
"city": "OLNEY",
"state": "IL",
"postal_code": "624504720",
"telephone_number": "618-395-4309",
"fax_number": "618-395-4507"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "GLENN",
"name_prefix": "Mr.",
"credential": "LSW, LCPC, CMH",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-10-08",
"last_updated": "2015-10-08",
"status": "A"
},
"taxonomies": [
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": null,
"license": null,
"primary": false
},
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LICENSED CLINICAL PROFESSIONAL COUNSELOR",
"identifier": "180.000994",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Olney, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.