Provider Demographics
NPI:1497229751
Name:JACKSON -DYER, TAMEKA LATOYA (IBCLC, CHW)
Entity Type:Individual
Prefix:
First Name:TAMEKA
Middle Name:LATOYA
Last Name:JACKSON -DYER
Suffix:
Gender:F
Credentials:IBCLC, CHW
Other - Prefix:
Other - First Name:TAMEKA
Other - Middle Name:LATOYA
Other - Last Name:JACKSON-SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IBCLC, CHW
Mailing Address - Street 1:18983 EDINBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-2825
Mailing Address - Country:US
Mailing Address - Phone:248-694-4402
Mailing Address - Fax:
Practice Address - Street 1:18983 EDINBOROUGH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-2825
Practice Address - Country:US
Practice Address - Phone:248-694-4402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
L-122778174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No172V00000XOther Service ProvidersCommunity Health Worker