Provider Demographics
NPI:1225411416
Name:RIVERS, JAMAL DEREK
Entity Type:Individual
Prefix:MR
First Name:JAMAL
Middle Name:DEREK
Last Name:RIVERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8872 PREVOST ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-2177
Mailing Address - Country:US
Mailing Address - Phone:248-633-5284
Mailing Address - Fax:313-740-7790
Practice Address - Street 1:8872 PREVOST ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-2177
Practice Address - Country:US
Practice Address - Phone:248-633-5284
Practice Address - Fax:313-740-7790
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374U00000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide