Provider Demographics
NPI:1407205008
Name:JACKSON, DALEDA
Entity Type:Individual
Prefix:
First Name:DALEDA
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 1:19178 RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2345
Mailing Address - Country:US
Mailing Address - Phone:313-605-8599
Mailing Address - Fax:
Practice Address - Street 1:17421 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3165
Practice Address - Country:US
Practice Address - Phone:313-297-2975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other