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General NPI Number Information
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NPI Number | 1841420346
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Entity Type | Individual
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Provider Name | NICOLE VANESSA JACKSON LMSW
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Gender | Female
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Dates
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Enumeration Date | 07/17/2009
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Last Update Date | 07/11/2022
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Provider Practice Location Address
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Address Line | 39293 PLYMOUTH RD STE 109A
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City | LIVONIA
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State | MI
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Zip | 48150-1060
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Country | US
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Telephone | 734-521-6579
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Fax | 734-943-6321
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Provider Business Mailing Address
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Address Line | 39293 PLYMOUTH RD SUITE 109A
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City | LIVONIA
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State | MI
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Zip | 48150-1060
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Country | US
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Telephone | 734-521-6579
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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 | 6801089011
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License Number State | MI
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