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NPI Code Detail

MEDICARE: KENYA JACKSON

MEDICARE: KENYA JACKSON
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
1106S00000XBehavior TechnicianMI

General Provider Information

NPI Number : 1760033088
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENYA JACKSON
Provider Business Mailing Address
First Line : 3290 W BIG BEAVER RD STE 510
Second Line :
City : TROY
State : MI
Zip : 48084-2917
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3290 W BIG BEAVER RD STE 510
Second Line :
City : TROY
State : MI
Zip : 48084-2917
Country : US
Telephone Number : 248-513-2731
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/27/2019
Last Update Date : 06/05/2024

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Directions to “ KENYA JACKSON ” Practice Location

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