Healthcare Provider Details

I. General information

NPI: 1427808401
Provider Name (Legal Business Name): YVONNE JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19178 HUBBELL ST
DETROIT MI
48235-1927
US

IV. Provider business mailing address

19178 HUBBELL ST
DETROIT MI
48235-1927
US

V. Phone/Fax

Practice location:
  • Phone: 313-743-7295
  • Fax:
Mailing address:
  • Phone: 313-743-7295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC2100X
TaxonomyContinence Care Registered Nurse
License Number47044381419
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number47044381419
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number47044381419
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License Number47044381419
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number47044381419
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number47044381419
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: