Provider Demographics
NPI:1508846320
Name:BUTLER-JACKSON, LOIS MICHELLE (MD, CWS)
Entity Type:Individual
Prefix:DR
First Name:LOIS
Middle Name:MICHELLE
Last Name:BUTLER-JACKSON
Suffix:
Gender:F
Credentials:MD, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37400 GARFIELD RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3648
Mailing Address - Country:US
Mailing Address - Phone:586-286-6389
Mailing Address - Fax:586-226-0403
Practice Address - Street 1:37400 GARFIELD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-3648
Practice Address - Country:US
Practice Address - Phone:586-286-6389
Practice Address - Fax:586-226-0403
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051182207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1106355961OtherBCBSM
MI4784286Medicaid
MI1106355961OtherBCBSM
MIE64369Medicare UPIN