Provider Demographics
NPI:1750405734
Name:JACKSON INNOVATIONS PLLC
Entity type:Organization
Organization Name:JACKSON INNOVATIONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GAYNELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-569-9846
Mailing Address - Street 1:20700 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4140
Mailing Address - Country:US
Mailing Address - Phone:248-569-9846
Mailing Address - Fax:248-569-1919
Practice Address - Street 1:20700 CIVIC CENTER DR
Practice Address - Street 2:SUITE 170
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4140
Practice Address - Country:US
Practice Address - Phone:248-569-9846
Practice Address - Fax:248-569-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010595151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty