Provider Demographics
NPI:1144573338
Name:JACKSON, TRACEE LOUISE (LPC)
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:LOUISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 ALLARD AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2812
Mailing Address - Country:US
Mailing Address - Phone:313-980-1254
Mailing Address - Fax:
Practice Address - Street 1:22901 W INDUSTRIAL DR STE 105
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1130
Practice Address - Country:US
Practice Address - Phone:313-980-1254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011830101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health