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General NPI Number Information
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NPI Number | 1700200086
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Entity Type | Individual
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Provider Name | DONALD JACKSON JR. MD
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Gender | Male
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Dates
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Enumeration Date | 02/07/2014
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Last Update Date | 02/07/2014
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Provider Practice Location Address
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Address Line | 2500 E GRAND BLVD MEDICAL DEPT
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City | DETROIT
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State | MI
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Zip | 48211-2006
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Country | US
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Telephone | 313-972-6202
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Fax | 313-972-6094
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Provider Business Mailing Address
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Address Line | 2500 E GRAND BLVD MEDICAL DEPT
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City | DETROIT
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State | MI
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Zip | 48211-2006
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Country | US
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Telephone | 313-972-6202
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Fax | 313-972-6094
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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 | 2083X0100X
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Taxonomy Name | Occupational Medicine Physician
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License Number | 43010441496
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License Number State | MI
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