Provider Demographics
NPI:1235525031
Name:JACKSON, ROSALYN DIONA (LBSW)
Entity Type:Individual
Prefix:MRS
First Name:ROSALYN
Middle Name:DIONA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:MS
Other - First Name:ROSALYN
Other - Middle Name:DIONA
Other - Last Name:HOPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBSW
Mailing Address - Street 1:100 RIVER PLACE DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 RIVER PLACE DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4274
Practice Address - Country:US
Practice Address - Phone:313-817-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802076524104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker