Healthcare Provider Details

I. General information

NPI: 1275652224
Provider Name (Legal Business Name): JACKIE ANN MALSOM LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 WEST WOOD
NEWAYGO MI
49337
US

IV. Provider business mailing address

1708 GARDNER AVE
NEWAYGO MI
49337-9062
US

V. Phone/Fax

Practice location:
  • Phone: 231-652-1780
  • Fax: 231-652-1786
Mailing address:
  • Phone: 231-652-1780
  • Fax: 231-652-1786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801087460
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: