Provider Demographics
NPI:1710696794
Name:JACKSON, NICOLE MARIE (BT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:MAUSOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 E WEXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49620-5107
Mailing Address - Country:US
Mailing Address - Phone:231-493-3944
Mailing Address - Fax:
Practice Address - Street 1:1810 CHARTWELL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-9283
Practice Address - Country:US
Practice Address - Phone:231-929-2354
Practice Address - Fax:231-929-2853
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician