Provider Demographics
NPI:1528182102
Name:JACKSON, JERRY CAMAL (BA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:CAMAL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
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Mailing Address - Street 1:507 E GROVE ST
Mailing Address - Street 2:
Mailing Address - City:SEBEWAING
Mailing Address - State:MI
Mailing Address - Zip Code:48759-1649
Mailing Address - Country:US
Mailing Address - Phone:989-883-2199
Mailing Address - Fax:989-883-2199
Practice Address - Street 1:1321 S FAYETTE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-1447
Practice Address - Country:US
Practice Address - Phone:989-792-8000
Practice Address - Fax:989-792-8445
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)