Provider Demographics
NPI:1710408943
Name:JACKSON, ALEXES
Entity Type:Individual
Prefix:
First Name:ALEXES
Middle Name:
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 1:1349 S HURON ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7021
Mailing Address - Country:US
Mailing Address - Phone:313-758-7693
Mailing Address - Fax:
Practice Address - Street 1:1349 S HURON ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-7021
Practice Address - Country:US
Practice Address - Phone:313-758-7693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401001747103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician