Healthcare Provider Details

I. General information

NPI: 1083679971
Provider Name (Legal Business Name): JACKSON OB/GYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W WASHINGTON AVE STE 60
JACKSON MI
49201-2180
US

IV. Provider business mailing address

300 W WASHINGTON AVE STE 60
JACKSON MI
49201-2180
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-0334
  • Fax: 517-787-2114
Mailing address:
  • Phone: 517-787-0334
  • Fax: 517-787-2114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMM012522
License Number StateMI

VIII. Authorized Official

Name: DR. MICHAEL MCDONNELL
Title or Position: OWNER
Credential: D.O.
Phone: 517-787-0334