Provider Demographics
NPI:1043606213
Name:JACKSON, EDWARD L (PSYD PLLC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PSYD PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 WELCH RD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-1562
Mailing Address - Country:US
Mailing Address - Phone:248-767-7927
Mailing Address - Fax:
Practice Address - Street 1:2900 WELCH RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48390-1562
Practice Address - Country:US
Practice Address - Phone:248-767-7927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016271103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical