Provider Demographics
NPI:1033840566
Name:JACKSON, SHARON LANELL
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LANELL
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 1:14411 ARTESIAN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2976
Mailing Address - Country:US
Mailing Address - Phone:248-688-2138
Mailing Address - Fax:
Practice Address - Street 1:14411 ARTESIAN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2976
Practice Address - Country:US
Practice Address - Phone:248-688-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703121728164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse