Healthcare Provider Details

I. General information

NPI: 1720206162
Provider Name (Legal Business Name): NANCY LOUISE JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9408 VAN ANTWERP RD
BRIGHTON MI
48116-6245
US

IV. Provider business mailing address

9408 VAN ANTWERP RD
BRIGHTON MI
48116-6245
US

V. Phone/Fax

Practice location:
  • Phone: 810-231-0207
  • Fax: 801-231-1693
Mailing address:
  • Phone: 810-231-0207
  • Fax: 801-231-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704159337
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: