Healthcare Provider Details

I. General information

NPI: 1609203694
Provider Name (Legal Business Name): LYNN JACKSON M.A., L.L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 PLYMOUTH AVE NE STE B
GRAND RAPIDS MI
49505
US

IV. Provider business mailing address

2324 SOUTHGATE DR SE
KENTWOOD MI
49508-0951
US

V. Phone/Fax

Practice location:
  • Phone: 616-345-0414
  • Fax:
Mailing address:
  • Phone: 616-345-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301009521
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: