Healthcare Provider Details

I. General information

NPI: 1508633124
Provider Name (Legal Business Name): NICOLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/09/2023
Certification Date: 12/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1484 N M 52
OWOSSO MI
48867-1235
US

IV. Provider business mailing address

1484 N M 52
OWOSSO MI
48867-1235
US

V. Phone/Fax

Practice location:
  • Phone: 770-373-5822
  • Fax: 248-712-4381
Mailing address:
  • Phone: 770-373-5822
  • Fax: 248-712-4381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: