MEDICARE: HEATHER ELIZABETH JACKSON ACNP

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	363LA2100X	Acute Care Nurse Practitioner	4704214316	MI
2	363L00000X	Nurse Practitioner	4704214316	MI

General Provider Information

NPI Number	:	1649602905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER ELIZABETH JACKSON ACNP

Provider Business Mailing Address
First Line	:	6286 PEPPER HILL ST
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2301
Country	:	US
Telephone Number	:	313-400-8007
Fax Number	:

Provider Business Practice Location Address
First Line	:	6286 PEPPER HILL ST
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2301
Country	:	US
Telephone Number	:	313-400-8007
Fax Number	:

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

Provider Enumeration Date	:	08/08/2013
Last Update Date	:	07/06/2023

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