Provider Demographics
NPI:1497953368
Name:JACKSON, HENRY BENSON (LLMSW)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:BENSON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 WASHINGTON BLVD APT 605
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1785
Mailing Address - Country:US
Mailing Address - Phone:313-965-1709
Mailing Address - Fax:
Practice Address - Street 1:10 PETERBORO DET. CENTRAL CITY COMMUNITY MENTAL HEALTH
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2722
Practice Address - Country:US
Practice Address - Phone:313-831-3160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010859671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical