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General NPI Number Information
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NPI Number | 1942987789
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Entity Type | Individual
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Provider Name | TYREL JACKSON H.A.D
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Gender | Male
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Dates
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Enumeration Date | 07/03/2023
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Last Update Date | 07/03/2023
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Provider Practice Location Address
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Address Line | 400 S STATE ST # 400
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City | ZEELAND
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State | MI
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Zip | 49464-2067
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Country | US
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Telephone | 616-207-8794
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Fax |
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Provider Business Mailing Address
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Address Line | 631 CLAYTON AVE NW
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City | WALKER
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State | MI
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Zip | 49534-3511
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Country | US
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Telephone | 616-406-8339
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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 | 237700000X
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Taxonomy Name | Hearing Instrument Specialist
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License Number | 3501008068
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License Number State | MI
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