Provider Demographics
NPI:1073919320
Name:HALLBERG, JACKIE (LMSW)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:HALLBERG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 BAKER ST FL 3
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:231-737-1335
Mailing Address - Fax:231-737-0534
Practice Address - Street 1:2700 BAKER ST FL 3
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-737-1335
Practice Address - Fax:231-737-0534
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010854411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231858Medicare Oscar/Certification