Healthcare Provider Details

I. General information

NPI: 1750492336
Provider Name (Legal Business Name): KIMBERLY ANN JACKSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 36TH ST SE
GRAND RAPIDS MI
49548-2319
US

IV. Provider business mailing address

1505 SPENCER ST NE
GRAND RAPIDS MI
49505-5530
US

V. Phone/Fax

Practice location:
  • Phone: 616-248-5272
  • Fax: 616-243-2302
Mailing address:
  • Phone: 616-818-9855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801086964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: