MEDICARE: MS. GAYNELLA JACKSON LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801059515	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	80-0-89-6833-0	OTHER	MI	BLUE CROSS BLUE SHIELD OF

General Provider Information

NPI Number	:	1154445138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GAYNELLA JACKSON LMSW

Provider Business Mailing Address
First Line	:	20700 CIVIC CENTER DR
Second Line	:	SUITE 170
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-4140
Country	:	US
Telephone Number	:	248-569-9846
Fax Number	:	248-569-1919

Provider Business Practice Location Address
First Line	:	20700 CIVIC CENTER DR
Second Line	:	SUITE 170
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-4140
Country	:	US
Telephone Number	:	248-569-9846
Fax Number	:	248-569-1919

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/09/2007

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