Healthcare Provider Details

I. General information

NPI: 1114738499
Provider Name (Legal Business Name): JACKSON HEALING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W FRANKLIN ST
JACKSON MI
49201-1674
US

IV. Provider business mailing address

2020 CASCADE DR
JACKSON MI
49203-3810
US

V. Phone/Fax

Practice location:
  • Phone: 734-726-4038
  • Fax: 517-905-5906
Mailing address:
  • Phone: 517-581-4710
  • Fax: 517-905-5906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HEATHER RENEE GOOLSBY
Title or Position: MASTER CLINICICAN
Credential: MA, LPC, NCC, CPT-C
Phone: 517-581-4710