=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063852614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONIA MARIE JACKSON LLBSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2013
-----------------------------------------------------
Last Update Date | 06/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 WEST FIFTH AVE
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-257-3746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1322 BANBURY PL
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-423-1178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 6802087390
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------