Provider Demographics
NPI:1821773177
Name:JACKSON, JAKIA MICHELLE
Entity Type:Individual
Prefix:
First Name:JAKIA
Middle Name:MICHELLE
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 1:2925 BRETON RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1745
Mailing Address - Country:US
Mailing Address - Phone:616-243-4336
Mailing Address - Fax:616-243-4423
Practice Address - Street 1:2925 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1745
Practice Address - Country:US
Practice Address - Phone:616-243-4336
Practice Address - Fax:616-243-4423
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other