Healthcare Provider Details

I. General information

NPI: 1609305937
Provider Name (Legal Business Name): LAUREN NICOLE JACKSON GC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18181 OAKWOOD BLVD STE 204
DEARBORN MI
48124-4082
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-593-7677
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number7201000016
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: