Provider Demographics
NPI:1942987789
Name:JACKSON, TYREL (HAD)
Entity Type:Individual
Prefix:
First Name:TYREL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 CLAYTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-3511
Mailing Address - Country:US
Mailing Address - Phone:616-406-8339
Mailing Address - Fax:
Practice Address - Street 1:400 S STATE ST # 400
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2067
Practice Address - Country:US
Practice Address - Phone:616-207-8794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501008068237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist