MEDICARE: GLORIA JACKSON MSW

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	6801019214	MI

General Provider Information

NPI Number	:	1205874369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA JACKSON MSW

Provider Business Mailing Address
First Line	:	220 W CONGRESS ST
Second Line	:	2ND FLOOR
City	:	DETROIT
State	:	MI
Zip	:	48226-3289
Country	:	US
Telephone Number	:	313-963-4979
Fax Number	:	313-963-4997

Provider Business Practice Location Address
First Line	:	220 W CONGRESS ST FL 2
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-3289
Country	:	US
Telephone Number	:	313-963-4979
Fax Number	:	313-963-4997

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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