Provider Demographics
NPI:1639469026
Name:JACKSON, KENNETH T (MASTERS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25506 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-6002
Mailing Address - Country:US
Mailing Address - Phone:313-492-5119
Mailing Address - Fax:
Practice Address - Street 1:25506 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-6002
Practice Address - Country:US
Practice Address - Phone:313-492-5119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)