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General NPI Number Information
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NPI Number | 1023153178
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Entity Type | Individual
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Provider Name | HERSHEL JACKSON MD
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Gender | Male
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3990 JOHN R ST
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City | DETROIT
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State | MI
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Zip | 48201-2018
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Country | US
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Telephone | 313-745-8040
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Fax |
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Provider Business Mailing Address
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Address Line | 23077 GREENFIELD RD STE 450
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City | SOUTHFIELD
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State | MI
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Zip | 48075-3760
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Country | US
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Telephone | 248-559-8810
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | 4301043930
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License Number State | MI
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