Provider Demographics
NPI:1366476780
Name:ROBERTSON, JACKQULINE D (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:JACKQULINE
Middle Name:D
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 FLUSHING RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-4534
Mailing Address - Country:US
Mailing Address - Phone:810-424-5998
Mailing Address - Fax:810-424-6347
Practice Address - Street 1:585 JEWETT RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-8729
Practice Address - Country:US
Practice Address - Phone:517-676-5405
Practice Address - Fax:517-676-5460
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802082860104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker