Healthcare Provider Details

I. General information

NPI: 1407088248
Provider Name (Legal Business Name): LORI JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 S DARTMOUTH ST
DETROIT MI
48217-1020
US

IV. Provider business mailing address

3103 S DARTMOUTH ST
DETROIT MI
48217-1020
US

V. Phone/Fax

Practice location:
  • Phone: 313-739-4339
  • Fax:
Mailing address:
  • Phone: 313-739-4339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberJ250546227628
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: