Provider Demographics
NPI:1598037665
Name:JACKSON, TAKIYAH (MA TLLP)
Entity Type:Individual
Prefix:MRS
First Name:TAKIYAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2445
Mailing Address - Country:US
Mailing Address - Phone:810-257-3714
Mailing Address - Fax:810-762-5234
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-257-3714
Practice Address - Fax:810-762-5234
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist