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General NPI Number Information
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NPI Number | 1922089531
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Entity Type | Individual
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Provider Name | FREDERICKA ARLENE JACKSON PH.D. CAC II
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Gender | Female
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Dates
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Enumeration Date | 11/10/2005
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 38815 DEQUINDRE RD
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City | TROY
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State | MI
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Zip | 48083-5769
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Country | US
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Telephone | 248-250-7323
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Fax |
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Provider Business Mailing Address
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Address Line | 43220 FOUNTAIN DR
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City | STERLING HEIGHTS
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State | MI
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Zip | 48313-2394
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Country | US
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Telephone | 586-532-9948
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Fax | 586-263-2762
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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 | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | 6301008884
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301008884
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License Number State | MI
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