Provider Demographics
NPI:1255595948
Name:JACKSON, CRYSTAL A (PHD, LLP)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WOODVIEW CT
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4112
Mailing Address - Country:US
Mailing Address - Phone:586-943-0563
Mailing Address - Fax:
Practice Address - Street 1:3011 W GRAND BLVD STE 413
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3011
Practice Address - Country:US
Practice Address - Phone:586-257-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013473103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling