Provider Demographics
NPI:1851595961
Name:JELLISON, JACKIE LYNN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:LYNN
Last Name:JELLISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69121 GATEWAY DR APT B1
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-8209
Mailing Address - Country:US
Mailing Address - Phone:574-855-0770
Mailing Address - Fax:
Practice Address - Street 1:960 E STATE ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9339
Practice Address - Country:US
Practice Address - Phone:269-445-2451
Practice Address - Fax:269-445-3216
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005297A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical