Provider Demographics
NPI:1881257178
Name:JACKSON, CHAD WALKER
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:WALKER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7709 RIVERVIEW DR APT 104
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-7960
Mailing Address - Country:US
Mailing Address - Phone:616-889-6781
Mailing Address - Fax:
Practice Address - Street 1:7709 RIVERVIEW DR APT 104
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-7960
Practice Address - Country:US
Practice Address - Phone:616-889-6781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI89619284Medicaid