Healthcare Provider Details

I. General information

NPI: 1699543439
Provider Name (Legal Business Name): SIMONE JACKSON O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 TELEGRAPH RD STE F1
BLOOMFIELD HILLS MI
48301-1775
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 248-633-2980
  • Fax: 248-633-2981
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201014414
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: