Provider Demographics
NPI:1275652224
Name:MALSOM, JACKIE ANN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:ANN
Last Name:MALSOM
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 1:1708 GARDNER AVE
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-9062
Mailing Address - Country:US
Mailing Address - Phone:231-652-1780
Mailing Address - Fax:231-652-1786
Practice Address - Street 1:12 WEST WOOD
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337
Practice Address - Country:US
Practice Address - Phone:231-652-1780
Practice Address - Fax:231-652-1786
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010874601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical