Provider Demographics
NPI:1215015680
Name:JACKSON-HAMMOND, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:JACKSON-HAMMOND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 WOODWARD AVE
Mailing Address - Street 2:STE 418
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2061
Mailing Address - Country:US
Mailing Address - Phone:313-831-8805
Mailing Address - Fax:
Practice Address - Street 1:3800 WOODWARD AVE
Practice Address - Street 2:STE 418
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2061
Practice Address - Country:US
Practice Address - Phone:313-831-8805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4180604Medicaid
MIB46034Medicare UPIN
MI4180604Medicaid