| Doctor Name: | EDWARD JACKSON |
| NPI Number: | 1043606213 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PSYD |
| License Number: | 6301016271 |
| Business Practice Address: | 11111 Hall Rd #303 Utica, MI - 483175711 |
| Business Phone Number: | 5869973153 |
| Business Fax Number: | 5869974956 |
| Mailing Address: | 11111 Hall Rd, #303 UTICA |
| State: | MI |
| Postal Code: | 483175711 |
| Phone Number: | 5869973153 |
| Fax Number: | 5869974956 |
| NPI Enumeration Date: | 04/14/2015 |
| NPI Last Update Date: | 04/14/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 6301016271 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |