Healthcare Provider Details

I. General information

NPI: 1629995980
Provider Name (Legal Business Name): KAYLA NICOLE JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WELLESLEY ST STE 1
WESTON MA
02493-1571
US

IV. Provider business mailing address

27691 ELDORADO PL
LATHRUP VILLAGE MI
48076-3454
US

V. Phone/Fax

Practice location:
  • Phone: 313-205-5070
  • Fax:
Mailing address:
  • Phone: 313-205-5070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704359630
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: