Provider Demographics
NPI:1639625833
Name:JACKSON, MICHAEL (MA, NCC,)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MA, NCC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 E ERIC DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-4206
Mailing Address - Country:US
Mailing Address - Phone:786-333-8982
Mailing Address - Fax:
Practice Address - Street 1:128 MUTE SWAN PLACE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711
Practice Address - Country:US
Practice Address - Phone:786-333-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEAC-0000107101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health