Healthcare Provider Details

I. General information

NPI: 1184131294
Provider Name (Legal Business Name): ANDREW JAMES JACKEL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 06/26/2021
Certification Date: 06/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39005 WILLOW CREEK PKWY
WESTLAND MI
48185-3826
US

IV. Provider business mailing address

39005 WILLOW CREEK PKWY
WESTLAND MI
48185-3826
US

V. Phone/Fax

Practice location:
  • Phone: 734-755-0268
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704274813
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: