Healthcare Provider Details

I. General information

NPI: 1114406998
Provider Name (Legal Business Name): DIAMOND JACKSON LLBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIAMOND WILFORD

II. Dates (important events)

Enumeration Date: 08/12/2018
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 OAKMAN BLVD
DETROIT MI
48238-3710
US

IV. Provider business mailing address

22141 WHITMORE ST
OAK PARK MI
48237-3525
US

V. Phone/Fax

Practice location:
  • Phone: 313-961-4890
  • Fax:
Mailing address:
  • Phone: 248-828-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6852090135
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: