Provider Demographics
NPI:1679238307
Name:JACKSON, JESSICA MIKELA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MIKELA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 COLLEGIATE WAY APT 526C
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9613
Practice Address - Country:US
Practice Address - Phone:231-736-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician