Provider Demographics
NPI:1306230875
Name:JACKSON RAMEY ROGERS DIVERSIFIED SERVICES
Entity Type:Organization
Organization Name:JACKSON RAMEY ROGERS DIVERSIFIED SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONNELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAMEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-242-0536
Mailing Address - Street 1:PO BOX 37204
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-0204
Mailing Address - Country:US
Mailing Address - Phone:242-242-0536
Mailing Address - Fax:
Practice Address - Street 1:23731 RADCLIFT ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1931
Practice Address - Country:US
Practice Address - Phone:248-242-0536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS630360466320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness