Healthcare Provider Details

I. General information

NPI: 1235209099
Provider Name (Legal Business Name): LEJA JACKSON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 S HURON ST
CHEBOYGAN MI
49721-2267
US

IV. Provider business mailing address

920 S HURON ST
CHEBOYGAN MI
49721-2267
US

V. Phone/Fax

Practice location:
  • Phone: 231-597-8192
  • Fax: 231-597-8463
Mailing address:
  • Phone: 231-597-8192
  • Fax: 231-597-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301042693
License Number StateMI

VIII. Authorized Official

Name: LORETTA M LEJA
Title or Position: OWNER
Credential: M D
Phone: 231-597-8192