Provider Demographics
NPI:1407262447
Name:HAWANYA JACKSON
Entity Type:Organization
Organization Name:HAWANYA JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT SUPPORT COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HAWANYA
Authorized Official - Middle Name:ABENA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA, RSST, QIDP
Authorized Official - Phone:313-942-5230
Mailing Address - Street 1:2425 ATKINSON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-2057
Mailing Address - Country:US
Mailing Address - Phone:313-942-5230
Mailing Address - Fax:
Practice Address - Street 1:2425 ATKINSON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-2057
Practice Address - Country:US
Practice Address - Phone:313-942-5230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803085548251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management