Provider Demographics
NPI:1073124772
Name:CRYSTAL A. JACKSON, PH.D. , LLP, LLC
Entity Type:Organization
Organization Name:CRYSTAL A. JACKSON, PH.D. , LLP, LLC
Other - Org Name:CRYSTAL A. JACKSON, PH.D. , LLP, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:586-943-0563
Mailing Address - Street 1:3011 W GRAND BLVD STE 413
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3011
Mailing Address - Country:US
Mailing Address - Phone:586-943-0563
Mailing Address - Fax:
Practice Address - Street 1:3011 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3096
Practice Address - Country:US
Practice Address - Phone:586-943-0563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-14
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty