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General NPI Number Information
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NPI Number | 1447792668
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Entity Type | Individual
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Provider Name | DEWAYNE JACKSON PERSONAL TRAINER
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Gender | Male
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Dates
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Enumeration Date | 11/07/2016
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Last Update Date | 11/07/2016
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Provider Practice Location Address
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Address Line | 4500 S SAGINAW ST
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City | FLINT
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State | MI
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Zip | 48507-2676
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Country | US
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Telephone | 810-265-7121
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Fax |
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Provider Business Mailing Address
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Address Line | 2446 GREEN PINE DR APT 5
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City | BURTON
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State | MI
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Zip | 48519-1185
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Country | US
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Telephone | 810-391-6328
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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 | 174H00000X
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Taxonomy Name | Health Educator
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License Number | T192947
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License Number State | MI
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