Provider Demographics
NPI:1093237943
Name:JACKSON, AUDREY LEE (MSW)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8594 N CANTON CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1310
Mailing Address - Country:US
Mailing Address - Phone:734-291-0007
Mailing Address - Fax:313-281-2235
Practice Address - Street 1:1061 INKSTER RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-3168
Practice Address - Country:US
Practice Address - Phone:734-291-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011056581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical