Provider Demographics
NPI:1073254330
Name:JACKSON, QUNISHA LASHA (N/A)
Entity Type:Individual
Prefix:MISS
First Name:QUNISHA
Middle Name:LASHA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 ROCKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2259
Mailing Address - Country:US
Mailing Address - Phone:248-579-3448
Mailing Address - Fax:
Practice Address - Street 1:1841 N PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-2235
Practice Address - Country:US
Practice Address - Phone:248-745-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-02
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator