Martina Shauntae Jackson

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

178.014194 Issued in IL

Practice address

2008 N Lawler Ave
Chicago, IL 60639-3136

Phone

(708) 860-1201

Fax

(708) 221-6679

NPI assigned

Apr 27, 2020

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

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.

• RL Group

  dba Reinvent Life Treatment Center

  • Substance Use Disorder Rehabilitation Clinic/Center
  • Chicago, IL
  • NPI 1376102814

  Professional

  NPD

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

{
    "created_epoch": "1587945600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1587945600000",
    "number": "1871114215",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2008 N LAWLER AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606393136",
            "telephone_number": "708-860-1201",
            "fax_number": "708-221-6679"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2008 N LAWLER AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606393136",
            "telephone_number": "708-860-1201",
            "fax_number": "708-221-6679"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "MARTINA",
        "middle_name": "SHAUNTAE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-04-27",
        "last_updated": "2020-04-27",
        "certification_date": "2020-04-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "178.014194",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSED PROFESSIONAL COUNSELOR",
            "identifier": "178.014194",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Linda Denise Jackson
• Lindsay McCarthy Jackson, APRN
• Malcolm Martin Jackson
• Marcus Jackson
• Marisa Zoe-Tatiana Jackson, PH.D.
• Matt Jackson, AGAC NP- BC
• Maudette M Jackson
• Morgan Elizabeth Jackson, MD
• Najla Jackson, APN
• Nusha Sylaj Jackson, FNP

• 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 Apr 27, 2020; 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.