Provider Demographics
NPI:1154968980
Name:JACKSON, FLUARRY DWAYNE JR (LLMSW)
Entity type:Individual
Prefix:
First Name:FLUARRY
Middle Name:DWAYNE
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5068 W CAMPUS DR APT G25
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-8850
Mailing Address - Country:US
Mailing Address - Phone:231-740-3455
Mailing Address - Fax:
Practice Address - Street 1:5068 W CAMPUS DR APT G25
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-8850
Practice Address - Country:US
Practice Address - Phone:231-740-3455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011049241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical