Provider Demographics
NPI:1154445138
Name:JACKSON, GAYNELLA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:GAYNELLA
Middle Name:
Last Name:JACKSON
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 1:20700 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4140
Mailing Address - Country:US
Mailing Address - Phone:248-569-9846
Mailing Address - Fax:248-569-1919
Practice Address - Street 1:20700 CIVIC CENTER DR
Practice Address - Street 2:SUITE 170
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4140
Practice Address - Country:US
Practice Address - Phone:248-569-9846
Practice Address - Fax:248-569-1919
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010595151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI80-0-89-6833-0OtherBLUE CROSS BLUE SHIELD OF
MION74200Medicare PIN