Healthcare Provider Details

I. General information

NPI: 1487564720
Provider Name (Legal Business Name): JUSTIN JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4675 HILL ST
CASS CITY MI
48726-1008
US

IV. Provider business mailing address

4675 HILL ST
CASS CITY MI
48726-1008
US

V. Phone/Fax

Practice location:
  • Phone: 989-872-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302419215
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: