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General NPI Number Information
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NPI Number | 1558207845
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Entity Type | Individual
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Provider Name | DE LORENCO L JACKSON
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Gender | Male
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Dates
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Enumeration Date | 04/28/2026
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Last Update Date | 04/28/2026
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Provider Practice Location Address
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Address Line | 8089 STADIUM DR STE B
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City | KALAMAZOO
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State | MI
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Zip | 49009-6270
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Country | US
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Telephone | 616-681-3828
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Fax | 269-869-5905
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Provider Business Mailing Address
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Address Line | 8089 STADIUM DR STE B
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City | KALAMAZOO
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State | MI
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Zip | 49009-6270
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Country | US
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Telephone | 616-681-3828
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Fax | 269-869-5905
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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 | 1835I0206X
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Taxonomy Name | Infectious Diseases Pharmacist
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License Number | 5306008385
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License Number State | MI
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