Provider Demographics
NPI:1265741789
Name:JACKSON, CHERYL ANN (LMSW, CAADC, CCS)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW, CAADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 S ETHEL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48217-1531
Mailing Address - Country:US
Mailing Address - Phone:313-775-6335
Mailing Address - Fax:
Practice Address - Street 1:2901 S ETHEL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48217-1531
Practice Address - Country:US
Practice Address - Phone:313-775-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 104100000X, 171M00000X, 172V00000X
MI68010924351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker