Provider Demographics
NPI:1417448721
Name:JACKSON, MARGARET ELAINE (LBSW)
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18080 FENMORE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3251
Mailing Address - Country:US
Mailing Address - Phone:313-531-0645
Mailing Address - Fax:
Practice Address - Street 1:8600 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2142
Practice Address - Country:US
Practice Address - Phone:313-875-7601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802004081104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker