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General NPI Number Information
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NPI Number | 1386205029
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Entity Type | Individual
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Provider Name | KALI MACKENZIE JACKSON-DIELEMAN LMSW-C, CAADC-DP
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Gender | Female
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Dates
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Enumeration Date | 06/24/2019
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 3300 36TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49512-2810
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Country | US
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Telephone | 616-965-3355
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Fax | 616-965-3460
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Provider Business Mailing Address
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Address Line | 2928 RURAH AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-3325
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Country | US
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Telephone | 269-491-5777
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801104938
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License Number State | MI
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