Provider Demographics
NPI:1194186239
Name:JACKSON, BRITTINY
Entity Type:Individual
Prefix:
First Name:BRITTINY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRITTINY
Other - Middle Name:
Other - Last Name:WIDEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23427 BOHN RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-8900
Mailing Address - Country:US
Mailing Address - Phone:734-934-0092
Mailing Address - Fax:
Practice Address - Street 1:35425 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-9800
Practice Address - Country:US
Practice Address - Phone:734-934-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker