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General NPI Number Information
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NPI Number | 1619685534
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Entity Type | Individual
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Provider Name | KELLONTREIA LAPORCHE JACKSON A-GNP-C
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Gender | Female
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Dates
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Enumeration Date | 11/09/2022
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Last Update Date | 01/28/2025
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Provider Practice Location Address
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Address Line | 41800 W 11 MILE RD STE 109
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City | NOVI
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State | MI
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Zip | 48375-1818
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Country | US
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Telephone | 248-660-1220
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Fax |
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Provider Business Mailing Address
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Address Line | 41800 W 11 MILE RD STE 109
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City | NOVI
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State | MI
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Zip | 48375-1818
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Country | US
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Telephone | 248-660-1220
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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 | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | RN259383
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 1176633
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 36993
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License Number State | TN
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Taxonomy #4
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 4704420181
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License Number State | MI
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Taxonomy #5
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | C-APN.0102805-C-NP
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License Number State | CO
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Taxonomy #6
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | H181146
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License Number State | IA
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