Healthcare Provider Details

I. General information

NPI: 1114284783
Provider Name (Legal Business Name): KAREN ANITA JACKSON LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8623 N WAYNE RD
WESTLAND MI
48185-1137
US

IV. Provider business mailing address

8623 N WAYNE RD
WESTLAND MI
48185-1137
US

V. Phone/Fax

Practice location:
  • Phone: 734-425-0636
  • Fax: 734-425-4771
Mailing address:
  • Phone: 734-425-0636
  • Fax: 734-425-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010520
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: