Provider Demographics
NPI:1457616609
Name:NOTTAGE-JACKSON, AMBROSIA (LPC,CRC)
Entity Type:Individual
Prefix:MRS
First Name:AMBROSIA
Middle Name:
Last Name:NOTTAGE-JACKSON
Suffix:
Gender:F
Credentials:LPC,CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22550 HALL RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1189
Mailing Address - Country:US
Mailing Address - Phone:586-850-3011
Mailing Address - Fax:
Practice Address - Street 1:22550 HALL RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1189
Practice Address - Country:US
Practice Address - Phone:313-550-3433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012758101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional