MEDICARE: DEVON LAMAR JACKSON M.D.

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	207ZN0500X	Neuropathology Physician	01089337A	IN
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207ZF0201X	Forensic Pathology Physician	4301513779	MI

General Provider Information

NPI Number	:	1699160275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVON LAMAR JACKSON M.D.

Provider Business Mailing Address
First Line	:	1300 E WARREN AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-1051
Country	:	US
Telephone Number	:	313-833-2504
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 E WARREN AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-1051
Country	:	US
Telephone Number	:	313-833-2504
Fax Number	:

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

Provider Enumeration Date	:	04/01/2015
Last Update Date	:	10/11/2025

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