| Doctor Name: | TANJA DECARLO-JACKSON |
| NPI Number: | 1073722161 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 1400 E 12 Mile Rd Madison Heights, MI - 480712651 |
| Business Phone Number: | 2485472223 |
| Business Fax Number: | |
| Mailing Address: | 19134 Montrose St, DETROIT |
| State: | MI |
| Postal Code: | 482352309 |
| Phone Number: | 3136534652 |
| Fax Number: | |
| NPI Enumeration Date: | 05/22/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |