Provider Demographics
NPI:1891032355
Name:JACKSON, TONYA MARIE (BS, QIDP)
Entity Type:Individual
Prefix:MS
First Name:TONYA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BS, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1168
Mailing Address - Country:US
Mailing Address - Phone:586-501-3070
Mailing Address - Fax:586-501-3079
Practice Address - Street 1:6900 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1168
Practice Address - Country:US
Practice Address - Phone:586-501-3070
Practice Address - Fax:586-501-3079
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI171M00000XMedicaid
AKMH0157Medicaid