Healthcare Provider Details

I. General information

NPI: 1922089531
Provider Name (Legal Business Name): FREDERICKA ARLENE JACKSON PH.D. CAC II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38815 DEQUINDRE RD
TROY MI
48083-5769
US

IV. Provider business mailing address

43220 FOUNTAIN DR
STERLING HEIGHTS MI
48313-2394
US

V. Phone/Fax

Practice location:
  • Phone: 248-250-7323
  • Fax:
Mailing address:
  • Phone: 586-532-9948
  • Fax: 586-263-2762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number6301008884
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301008884
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: