Provider Demographics
NPI:1407088248
Name:JACKSON, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 S DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48217-1020
Mailing Address - Country:US
Mailing Address - Phone:313-739-4339
Mailing Address - Fax:
Practice Address - Street 1:3103 S DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48217-1020
Practice Address - Country:US
Practice Address - Phone:313-739-4339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJ250546227628347C00000X
372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No347C00000XTransportation ServicesPrivate Vehicle