Individual
MR. KENNETH T JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MASTERS
Contact information
Practice address
25506 VIRGINIA DR, WARREN, MI 48091-6002
(313) 492-5119
Mailing address
25506 VIRGINIA DR, WARREN, MI 48091-6002
(313) 492-5119
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
MI
Other
Enumeration date
04/19/2011
Last updated
04/19/2011
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