Individual
JOANN MICHELLE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PSY.D.
Contact information
Practice address
403 E MADISON ST, SOUTH BEND, IN 46617-2322
(574) 533-1234
(574) 537-2652
Mailing address
330 LAKEVIEW DR, GOSHEN, IN 46528-9365
(574) 533-1234
(574) 537-2652
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
20040982A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200200700A
—
IN
Enumeration date
07/28/2006
Last updated
09/27/2010
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