Provider Demographics
NPI:1033693155
Name:JACKSON, TYLER (LLMSW)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26184 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2084
Mailing Address - Country:US
Mailing Address - Phone:313-389-7516
Mailing Address - Fax:313-389-7510
Practice Address - Street 1:26184 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2084
Practice Address - Country:US
Practice Address - Phone:313-389-7516
Practice Address - Fax:313-389-7510
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801103320104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker