=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033585955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON'S COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2015
-----------------------------------------------------
Last Update Date | 01/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | G3163 FLUSHING RD SUITE 214
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48504-4365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-845-6465
-----------------------------------------------------
Fax | 810-733-7317
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 314
-----------------------------------------------------
City | SWARTZ CREEK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48473-0314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-845-6465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROPRIETOR/PSYCHOTHERAPIST
-----------------------------------------------------
Name | MS. VALERIE F JACKSON
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 810-845-6465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 6801077180
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------