Healthcare Provider Details

I. General information

NPI: 1215696927
Provider Name (Legal Business Name): ANTHOLYN FLOYED-JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 GRAND RIVER AVE
DETROIT MI
48208-2962
US

IV. Provider business mailing address

17167 BONSTELLE AVE
SOUTHFIELD MI
48075-3470
US

V. Phone/Fax

Practice location:
  • Phone: 313-557-8620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: