Provider Demographics
NPI:1093835043
Name:JACKSON, HARUMBEE FOWLER (OTR)
Entity Type:Individual
Prefix:MRS
First Name:HARUMBEE
Middle Name:FOWLER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4571 W OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1223
Mailing Address - Country:US
Mailing Address - Phone:313-342-3064
Mailing Address - Fax:313-345-9906
Practice Address - Street 1:4571 W OUTER DR
Practice Address - Street 2:29510 7 MILE RD, LIVONIA, MI 48152
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1223
Practice Address - Country:US
Practice Address - Phone:313-342-3064
Practice Address - Fax:313-345-9906
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5201005629225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM08160007Medicare ID - Type UnspecifiedOCCUPATIONAL THERAPY