Provider Demographics
NPI:1740411636
Name:JACKSON, MICHELE DENISE (RI-J0808181554)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RI-J0808181554
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10700 MACARTHUR BLVD
Mailing Address - Street 2:STE 12
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-5298
Mailing Address - Country:US
Mailing Address - Phone:510-568-2432
Mailing Address - Fax:510-568-3912
Practice Address - Street 1:10700 MACARTHUR BLVD
Practice Address - Street 2:STE 12
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-5298
Practice Address - Country:US
Practice Address - Phone:510-568-2432
Practice Address - Fax:510-568-3912
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-J808181554101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA941702064OtherALCOHOL AND OTHER DRUG