Provider Demographics
NPI:1205214988
Name:JACKSON, SIMONE RENE (MAS (AJS))
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:RENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MAS (AJS)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 DUPONT ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505-2068
Mailing Address - Country:US
Mailing Address - Phone:810-348-3303
Mailing Address - Fax:810-733-7623
Practice Address - Street 1:1044 GILBERT ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3527
Practice Address - Country:US
Practice Address - Phone:810-422-9406
Practice Address - Fax:810-733-7623
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)