Basic Information
| Provider Information | |||||||||
| NPI: | 1598193773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | RAE ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1870 LEONARD ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169569619 | ||||||||
| FaxNumber: | 6169568033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2013 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 99058975A | IN | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6801095548 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1598193773 | 05 | MI | MEDICAID |