Provider Demographics
NPI:1467278945
Name:JACKSON, GIVAUNNI S
Entity type:Individual
Prefix:
First Name:GIVAUNNI
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8308 OFFICE PARK DR STE 3
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2075
Mailing Address - Country:US
Mailing Address - Phone:810-955-6021
Mailing Address - Fax:
Practice Address - Street 1:8308 OFFICE PARK DR STE 3
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2075
Practice Address - Country:US
Practice Address - Phone:810-215-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI685111191631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical