Healthcare Provider Details

I. General information

NPI: 1881049260
Provider Name (Legal Business Name): CHRISTINE JACKSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9115 WARWICK
DETROIT MI
48228
US

IV. Provider business mailing address

9115 WARWICK ST
DETROIT MI
48228-1730
US

V. Phone/Fax

Practice location:
  • Phone: 810-287-6198
  • Fax:
Mailing address:
  • Phone: 810-287-6198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801068895
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: