MEDICARE: ORTAGUS DAVOUR JACKSON CERTIFICATE

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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	172V00000X	MI

General Provider Information

NPI Number	:	1376491258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ORTAGUS DAVOUR JACKSON CERTIFICATE

Provider Business Mailing Address
First Line	:	18939 SCHOENHERR ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-2205
Country	:	US
Telephone Number	:	313-300-7599
Fax Number	:

Provider Business Practice Location Address
First Line	:	18939 SCHOENHERR ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-2205
Country	:	US
Telephone Number	:	313-300-7599
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2026
Last Update Date	:	03/18/2026

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Directions to “ ORTAGUS DAVOUR JACKSON CERTIFICATE” Practice Location

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