Provider Demographics
NPI:1316115819
Name:PRICE, JACKIE M (MSW)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:M
Last Name:PRICE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:M
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:1086 CHARLES H ORNDORF DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116
Mailing Address - Country:US
Mailing Address - Phone:810-220-0271
Mailing Address - Fax:
Practice Address - Street 1:1086 CHARLES H ORNDORF DRIVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116
Practice Address - Country:US
Practice Address - Phone:810-220-0271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL10963341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical