MEDICARE: YVONNE JACKSON RN

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	163WC2100X	Continence Care Registered Nurse	47044381419	MI
2	163WH0200X	Home Health Registered Nurse	47044381419	MI
3	163WI0500X	Infusion Therapy Registered Nurse	47044381419	MI
4	163WI0600X	Infection Control Registered Nurse	47044381419	MI
5	163WW0000X	Wound Care Registered Nurse	47044381419	MI
6	163W00000X	Registered Nurse	47044381419	MI

General Provider Information

NPI Number	:	1427808401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YVONNE JACKSON RN

Provider Business Mailing Address
First Line	:	19178 HUBBELL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-1927
Country	:	US
Telephone Number	:	313-743-7295
Fax Number	:

Provider Business Practice Location Address
First Line	:	19178 HUBBELL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-1927
Country	:	US
Telephone Number	:	313-743-7295
Fax Number	:

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

Provider Enumeration Date	:	03/25/2024
Last Update Date	:	03/25/2024

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