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General NPI Number Information
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NPI Number | 1053787572
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Entity Type | Individual
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Provider Name | KELSEY JACKSON MOTR/L
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Gender | Female
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Dates
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Enumeration Date | 08/19/2015
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Last Update Date | 06/06/2018
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Provider Practice Location Address
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Address Line | 3901 BEAUBIEN ST
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City | DETROIT
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State | MI
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Zip | 48201
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Country | US
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Telephone | 816-805-0963
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Fax |
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Provider Business Mailing Address
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Address Line | 30080 MANOR DR
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City | MADISON HEIGHTS
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State | MI
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Zip | 48071-2237
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Country | US
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Telephone | 816-805-0963
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 17-03012
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 5201009867
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License Number State | MI
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