Provider Demographics
NPI:1821832403
Name:JACKSON, SUMMER JAYNE
Entity type:Individual
Prefix:
First Name:SUMMER
Middle Name:JAYNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 STEWART RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-9636
Mailing Address - Country:US
Mailing Address - Phone:734-790-6242
Mailing Address - Fax:
Practice Address - Street 1:120 STEVENS ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1526
Practice Address - Country:US
Practice Address - Phone:614-469-3870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician