Provider Demographics
NPI:1083960942
Name:JACKSON, KASSANDRA LYNN (LMSW)
Entity type:Individual
Prefix:MS
First Name:KASSANDRA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 PROVINCIAL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-2539
Mailing Address - Country:US
Mailing Address - Phone:248-830-7782
Mailing Address - Fax:
Practice Address - Street 1:17940 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4444
Practice Address - Country:US
Practice Address - Phone:517-234-3627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093643104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical