Provider Demographics
NPI:1003681560
Name:JACKSON, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40583 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7120
Mailing Address - Country:US
Mailing Address - Phone:586-873-5504
Mailing Address - Fax:
Practice Address - Street 1:17920 WINSOME
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-3168
Practice Address - Country:US
Practice Address - Phone:313-422-5832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide