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NPI Code Detail

MEDICARE: MACKENZIE JACKS PA-C

MEDICARE: MACKENZIE JACKS PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant5601007103MI

General Provider Information

NPI Number : 1285054254
Entity Type Code : Individual
Provider Name (Legal Business Name) : MACKENZIE JACKS PA-C
Provider Business Mailing Address
First Line : 3040 E 7 MILE RD
Second Line :
City : DETROIT
State : MI
Zip : 48234-1662
Country : US
Telephone Number : 313-368-0705
Fax Number :
Provider Business Practice Location Address
First Line : 3040 E 7 MILE RD
Second Line :
City : DETROIT
State : MI
Zip : 48234-1662
Country : US
Telephone Number : 313-368-0705
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/17/2014
Last Update Date : 02/03/2015

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Directions to “ MACKENZIE JACKS PA-C” Practice Location

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