Healthcare Provider Details

I. General information

NPI: 1184551707
Provider Name (Legal Business Name): CORNESHA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W SPRING ST
MARQUETTE MI
49855-4661
US

IV. Provider business mailing address

PO BOX 272
NEWBERRY MI
49868-0272
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-9835
  • Fax:
Mailing address:
  • Phone: 906-225-9835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: