Provider Demographics
NPI:1982444360
Name:STEWART-JACKSON, JILLIAN
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:STEWART-JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:C/O 15343 FORRER
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227
Mailing Address - Country:US
Mailing Address - Phone:313-335-3734
Mailing Address - Fax:
Practice Address - Street 1:C/O 15343 FORRER
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227
Practice Address - Country:US
Practice Address - Phone:313-335-3734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily