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General NPI Number Information
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NPI Number | 1205090354
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Entity Type | Organization
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Legal Business Name | JACKSON HEALTH SERVICES
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Dates
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Enumeration Date | 07/17/2008
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Last Update Date | 07/17/2008
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Provider Practice Location Address
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Address Line | 3800 WOODWARD AVE STE. 418
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City | DETROIT
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State | MI
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Zip | 48201-2061
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Country | US
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Telephone | 313-831-8805
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Fax | 313-832-8206
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Provider Business Mailing Address
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Address Line | 3800 WOODWARD AVE STE. 418
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City | DETROIT
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State | MI
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Zip | 48201-2061
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Country | US
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Telephone | 313-831-8805
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Fax | 313-832-8206
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. MARY L. JACKSON-HAMMOND
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Credential | M.D.
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Telephone | 313-831-8805
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 4301046737
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License Number State | MI
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