Provider Demographics
NPI:1841420346
Name:JACKSON, NICOLE VANESSA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:VANESSA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:VANESSA
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:39293 PLYMOUTH RD
Mailing Address - Street 2:SUITE 109A
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1060
Mailing Address - Country:US
Mailing Address - Phone:734-521-6579
Mailing Address - Fax:
Practice Address - Street 1:39293 PLYMOUTH RD
Practice Address - Street 2:STE 109A
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1060
Practice Address - Country:US
Practice Address - Phone:734-521-6579
Practice Address - Fax:734-943-6321
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010890111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical