Provider Demographics
NPI:1760945414
Name:JACKSON, KATIE MICHELLE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3792 DEIBEL DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-7229
Mailing Address - Country:US
Mailing Address - Phone:989-860-1601
Mailing Address - Fax:
Practice Address - Street 1:3600 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2301
Practice Address - Country:US
Practice Address - Phone:989-510-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6401015169101YP2500X
MI6401015169101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional