Provider Demographics
NPI:1396044269
Name:JACKSON, KEELY (CERTIFIED)
Entity Type:Individual
Prefix:MS
First Name:KEELY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21268 VENICE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1315
Mailing Address - Country:US
Mailing Address - Phone:586-948-8954
Mailing Address - Fax:586-948-8954
Practice Address - Street 1:21268 VENICE DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1315
Practice Address - Country:US
Practice Address - Phone:586-948-8954
Practice Address - Fax:586-948-8954
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO911223174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI208443128OtherEMPLOYER IDENTIFICATION NUMBER