Provider Demographics
NPI:1770254658
Name:JACKSON, NICOLE NYOKA
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:NYOKA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:NYOKA
Other - Last Name:CALLAWAY-ALLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18600 GODDARD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-4400
Mailing Address - Country:US
Mailing Address - Phone:313-205-3317
Mailing Address - Fax:
Practice Address - Street 1:18600 GODDARD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-4400
Practice Address - Country:US
Practice Address - Phone:313-205-3317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider