MEDICARE: KAY ELLEN JACKSON R.PH.

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	1835P1200X	Pharmacotherapy Pharmacist	5302027100	MI

General Provider Information

NPI Number	:	1336559632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAY ELLEN JACKSON R.PH.

Provider Business Mailing Address
First Line	:	4735 BENTLEY DR
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48098-4447
Country	:	US
Telephone Number	:	248-885-8678
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 E 13 MILE RD
Second Line	:
City	:	MADISON HTS
State	:	MI
Zip	:	48071-1533
Country	:	US
Telephone Number	:	248-307-4933
Fax Number	:	248-307-4965

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

Provider Enumeration Date	:	05/07/2014
Last Update Date	:	05/07/2014

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