Provider Demographics
NPI:1659993251
Name:JACKSON, KELLY LYNNE (LLMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNNE
Other - Last Name:OTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27732 MORAN ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-2929
Mailing Address - Country:US
Mailing Address - Phone:561-506-8977
Mailing Address - Fax:
Practice Address - Street 1:1255 N OAKLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1545
Practice Address - Country:US
Practice Address - Phone:248-599-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical