Healthcare Provider Details

I. General information

NPI: 1841200722
Provider Name (Legal Business Name): JACKSON CARDIOLOGY & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PAGE AVE
JACKSON MI
49201
US

IV. Provider business mailing address

205 PAGE AVE
JACKSON MI
49201
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-3577
  • Fax: 517-787-4280
Mailing address:
  • Phone: 517-787-3577
  • Fax: 517-787-4280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. DAWN R NOBLE
Title or Position: CREDENTIALING/BILLING
Credential:
Phone: 517-787-3577