Provider Demographics
NPI:1073878674
Name:JACKSON, AMELIA C (LMSW)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:C
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:248-620-6400
Mailing Address - Fax:248-620-6405
Practice Address - Street 1:6549 TOWN CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4824
Practice Address - Country:US
Practice Address - Phone:248-620-6400
Practice Address - Fax:248-620-6405
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010944461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical