Healthcare Provider Details

I. General information

NPI: 1649869488
Provider Name (Legal Business Name): LEAH JACKSON CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 JACKSON AVE
ANN ARBOR MI
48103-3814
US

IV. Provider business mailing address

2355 JACKSON AVE
ANN ARBOR MI
48103-3814
US

V. Phone/Fax

Practice location:
  • Phone: 734-794-0162
  • Fax: 734-794-0168
Mailing address:
  • Phone: 734-794-0162
  • Fax: 734-794-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303019851
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: