Healthcare Provider Details

I. General information

NPI: 1548185796
Provider Name (Legal Business Name): KYMANI MAHAFFEY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22206 W WARREN AVE
REDFORD MI
48239-1024
US

IV. Provider business mailing address

22430 GRATIOT AVE
EASTPOINTE MI
48021-7048
US

V. Phone/Fax

Practice location:
  • Phone: 313-804-8635
  • Fax: 517-515-7469
Mailing address:
  • Phone: 313-804-8635
  • Fax: 517-515-7469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number189908017
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: