Provider Demographics
NPI:1568084861
Name:JACKSON, ZANNIE ROY JR (PEER SUPPORT SPECIAL)
Entity Type:Individual
Prefix:
First Name:ZANNIE
Middle Name:ROY
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36801 ANN ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36801 ANN ARBOR TRL
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3422
Practice Address - Country:US
Practice Address - Phone:313-728-1884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist