Provider Demographics
NPI:1497072235
Name:JACKSON, DAWN MAUREEN (LMSW)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MAUREEN
Last Name:JACKSON
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 1:21261 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3125
Mailing Address - Country:US
Mailing Address - Phone:586-771-7253
Mailing Address - Fax:
Practice Address - Street 1:21261 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3125
Practice Address - Country:US
Practice Address - Phone:586-771-7253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020612561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical