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NPI Code Detail

MEDICARE: MICHAEL TIMOTHY JACKSON SR. BSW

MEDICARE: MICHAEL TIMOTHY JACKSON SR. BSW
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
1104100000XSocial Worker6802089884MI

General Provider Information

NPI Number : 1528779816
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHAEL TIMOTHY JACKSON SR. BSW
Provider Business Mailing Address
First Line : PO BOX 6159
Second Line :
City : JACKSON
State : MI
Zip : 49204-6159
Country : US
Telephone Number : 517-783-3434
Fax Number : 517-782-6446
Provider Business Practice Location Address
First Line : 216 E BIDDLE ST
Second Line :
City : JACKSON
State : MI
Zip : 49203-1800
Country : US
Telephone Number : 517-783-3434
Fax Number : 517-782-6446
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/08/2022
Last Update Date : 12/08/2022

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