MEDICARE: CATRINA MESHELL LEE-JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1295214062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CATRINA MESHELL LEE-JACKSON

Provider Business Mailing Address
First Line	:	15227 ROSSINI DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-2052
Country	:	US
Telephone Number	:	313-627-8455
Fax Number	:

Provider Business Practice Location Address
First Line	:	15227 ROSSINI DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-2052
Country	:	US
Telephone Number	:	313-627-8455
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2018
Last Update Date	:	08/12/2018

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