MEDICARE: JOY KATHERINE JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	172V00000X	Community Health Worker
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	MI
3	101Y00000X	Counselor

General Provider Information

NPI Number	:	1285200667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOY KATHERINE JACKSON

Provider Business Mailing Address
First Line	:	4273 CORPORATE WAY
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-1082
Country	:	US
Telephone Number	:	989-953-4357
Fax Number	:

Provider Business Practice Location Address
First Line	:	4273 CORPORATE WAY
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-1082
Country	:	US
Telephone Number	:	989-953-4357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2021
Last Update Date	:	05/26/2026

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