Provider Demographics
NPI:1821770207
Name:JACKSON, DELPHINE ELAINE (MSW)
Entity Type:Individual
Prefix:MS
First Name:DELPHINE
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:DELPHINE
Other - Middle Name:ELAINE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:1281 MICHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-3054
Mailing Address - Country:US
Mailing Address - Phone:616-268-8787
Mailing Address - Fax:
Practice Address - Street 1:1281 MICHAEL AVE
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-3054
Practice Address - Country:US
Practice Address - Phone:616-268-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851105932104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker