Provider Demographics
NPI:1205251071
Name:JACKSON, KERRIE DIANNE (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:KERRIE
Middle Name:DIANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 PARK STREET
Mailing Address - Street 2:PLAINWELL COUNSELING CENTER
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080
Mailing Address - Country:US
Mailing Address - Phone:269-685-9401
Mailing Address - Fax:269-685-9403
Practice Address - Street 1:319 PARK STREET
Practice Address - Street 2:PLAINWELL COUNSELING CENTER
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080
Practice Address - Country:US
Practice Address - Phone:269-685-9401
Practice Address - Fax:269-685-9403
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096023104100000X, 104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker