Provider Demographics
NPI:1376941187
Name:JACKSON, DEBBIE (LPN)
Entity Type:Individual
Prefix:
First Name:DEBBIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12800 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2061
Mailing Address - Country:US
Mailing Address - Phone:313-824-8000
Mailing Address - Fax:313-824-5589
Practice Address - Street 1:12800 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2061
Practice Address - Country:US
Practice Address - Phone:313-824-8000
Practice Address - Fax:313-824-5589
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703108555164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703108555OtherLPN LICENSE