Provider Demographics
NPI:1942294947
Name:PAYNE-JACKSON, VALERIE (DO)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:PAYNE-JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 S ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-3532
Mailing Address - Country:US
Mailing Address - Phone:248-656-9100
Mailing Address - Fax:248-656-9157
Practice Address - Street 1:1812 S ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-3532
Practice Address - Country:US
Practice Address - Phone:248-656-9100
Practice Address - Fax:248-656-9157
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVP008011207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4321981Medicaid
MIE30469Medicare UPIN