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General NPI Number Information
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NPI Number | 1649816281
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Entity Type | Individual
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Provider Name | RUSSCHEL JANE JACKSON DNP
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Gender | Female
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Dates
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Enumeration Date | 11/19/2019
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Last Update Date | 11/19/2019
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Provider Practice Location Address
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Address Line | 3601 W 13 MILE RD
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City | ROYAL OAK
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State | MI
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Zip | 48073-6712
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Country | US
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Telephone | 248-898-2800
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Fax |
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Provider Business Mailing Address
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Address Line | 11311 GRAYFIELD
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City | REDFORD
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State | MI
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Zip | 48239-1451
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Country | US
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Telephone | 313-303-1124
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 13550
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 163WC0200X
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Taxonomy Name | Critical Care Medicine Registered Nurse
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License Number | 4704203865
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License Number State | MI
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