Provider Demographics
NPI:1962428748
Name:JACKSON, RICKEY T (PSY S)
Entity type:Individual
Prefix:PROF
First Name:RICKEY
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PSY S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17360 BIRCHCREST DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2733
Mailing Address - Country:US
Mailing Address - Phone:313-861-4027
Mailing Address - Fax:
Practice Address - Street 1:20600 EUREKA RD
Practice Address - Street 2:SUITE 819
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-5343
Practice Address - Country:US
Practice Address - Phone:734-285-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
MI6301008412103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist