Provider Demographics
NPI:1346822863
Name:GADSON, JACQUELINE MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:GADSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5119 HIGHLAND RD STE 311
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1915
Mailing Address - Country:US
Mailing Address - Phone:248-429-9145
Mailing Address - Fax:248-256-0012
Practice Address - Street 1:24430 FORD RD STE B
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3280
Practice Address - Country:US
Practice Address - Phone:248-429-9145
Practice Address - Fax:248-256-0012
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009747101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional