Provider Demographics
NPI:1497985113
Name:JACKSON, STEPHANIE C (LMSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:C
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 1:616 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8645
Mailing Address - Country:US
Mailing Address - Phone:810-936-0079
Mailing Address - Fax:
Practice Address - Street 1:616 W BROAD ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8645
Practice Address - Country:US
Practice Address - Phone:810-936-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010959741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497985113Medicaid