Provider Demographics
NPI:1922089531
Name:JACKSON, FREDERICKA ARLENE (PHD CAC II)
Entity Type:Individual
Prefix:DR
First Name:FREDERICKA
Middle Name:ARLENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43220 FOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-2394
Mailing Address - Country:US
Mailing Address - Phone:586-532-9948
Mailing Address - Fax:586-263-2762
Practice Address - Street 1:38815 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5769
Practice Address - Country:US
Practice Address - Phone:248-250-7323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008884103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM16310Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST