MEDICARE: LORI 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	347C00000X	Private Vehicle	J250546227628	MI
2	372500000X	Chore Provider

General Provider Information

NPI Number	:	1407088248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI JACKSON

Provider Business Mailing Address
First Line	:	3103 S DARTMOUTH ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48217-1020
Country	:	US
Telephone Number	:	313-739-4339
Fax Number	:

Provider Business Practice Location Address
First Line	:	3103 S DARTMOUTH ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48217-1020
Country	:	US
Telephone Number	:	313-739-4339
Fax Number	:

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

Provider Enumeration Date	:	08/12/2009
Last Update Date	:	08/12/2009

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Directions to “ LORI JACKSON ” Practice Location

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