Provider Demographics
NPI:1578851887
Name:BURRELL-JACKSON, CAROL (PHD, MSW, LMSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BURRELL-JACKSON
Suffix:
Gender:F
Credentials:PHD, MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 PACKARD ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2054
Mailing Address - Country:US
Mailing Address - Phone:734-929-6509
Mailing Address - Fax:734-929-6553
Practice Address - Street 1:3810 PACKARD ST
Practice Address - Street 2:SUITE 250
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2054
Practice Address - Country:US
Practice Address - Phone:734-929-6509
Practice Address - Fax:734-929-6553
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010358811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical