Provider Demographics
NPI:1619390713
Name:JACKSON, VANESSA L
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LBSW
Mailing Address - Street 1:35300 NANKIN BLVD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7222
Mailing Address - Country:US
Mailing Address - Phone:888-355-5433
Mailing Address - Fax:
Practice Address - Street 1:35300 NANKIN BLVD
Practice Address - Street 2:SUITE 601
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-7222
Practice Address - Country:US
Practice Address - Phone:888-355-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILBSW6802085900171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator