Healthcare Provider Details

I. General information

NPI: 1437174638
Provider Name (Legal Business Name): PHILIP JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HAMLIN DR
INKSTER MI
48141-2348
US

IV. Provider business mailing address

26650 EUREKA RD SUITE C-1
TAYLOR MI
48180-4835
US

V. Phone/Fax

Practice location:
  • Phone: 313-561-5100
  • Fax: 313-565-0309
Mailing address:
  • Phone: 734-941-4991
  • Fax: 734-941-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301025901
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: