Provider Demographics
NPI:1417721879
Name:JACKSON, CATRINA
Entity Type:Individual
Prefix:
First Name:CATRINA
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 1:15900 W 10 MILE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2079
Mailing Address - Country:US
Mailing Address - Phone:248-378-7145
Mailing Address - Fax:
Practice Address - Street 1:17669 MCINTYRE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-2369
Practice Address - Country:US
Practice Address - Phone:833-523-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care