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General NPI Number Information
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NPI Number | 1548185796
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Entity Type | Individual
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Provider Name | KYMANI MAHAFFEY JACKSON
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Gender | Female
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Dates
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Enumeration Date | 08/13/2026
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Last Update Date | 08/13/2026
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Provider Practice Location Address
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Address Line | 22206 W WARREN AVE
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City | REDFORD
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State | MI
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Zip | 48239-1024
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Country | US
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Telephone | 313-804-8635
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Fax | 517-515-7469
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Provider Business Mailing Address
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Address Line | 22430 GRATIOT AVE
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City | EASTPOINTE
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State | MI
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Zip | 48021-7048
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Country | US
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Telephone | 313-804-8635
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Fax | 517-515-7469
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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 | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | 189908017
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License Number State | MI
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