Healthcare Provider Details

I. General information

NPI: 1164832200
Provider Name (Legal Business Name): ANGELL LOVE-JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20100 GREENFIELD RD
DETROIT MI
48235-1803
US

IV. Provider business mailing address

15139 GLASTONBURY AVE
DETROIT MI
48223-3602
US

V. Phone/Fax

Practice location:
  • Phone: 313-342-2699
  • Fax:
Mailing address:
  • Phone: 313-835-1541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801072692
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: