MEDICARE: TABITA 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	237700000X	Hearing Instrument Specialist	3500104616	MI

General Provider Information

NPI Number	:	1316004880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITA JACKSON

Provider Business Mailing Address
First Line	:	2550 RANDALL AVE NW
Second Line	:
City	:	WALKER
State	:	MI
Zip	:	49534-7541
Country	:	US
Telephone Number	:	616-633-4997
Fax Number	:

Provider Business Practice Location Address
First Line	:	11160 WJ PRESLEY PKWY STE 102
Second Line	:
City	:	ALLENDALE
State	:	MI
Zip	:	49401-8075
Country	:	US
Telephone Number	:	616-384-2810
Fax Number	:

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	04/29/2024

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