Provider Demographics
NPI:1205874369
Name:JACKSON, GLORIA (MSW)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ACSW
Mailing Address - Street 1:220 W CONGRESS ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-3289
Mailing Address - Country:US
Mailing Address - Phone:313-963-4979
Mailing Address - Fax:313-963-4997
Practice Address - Street 1:220 W CONGRESS ST FL 2
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-3289
Practice Address - Country:US
Practice Address - Phone:313-963-4979
Practice Address - Fax:313-963-4997
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010192141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical