Provider Demographics
NPI:1962823633
Name:TAYLOR, JACKITRA EUNICE
Entity Type:Individual
Prefix:
First Name:JACKITRA
Middle Name:EUNICE
Last Name:TAYLOR
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 1:8181 N WAYNE RD
Mailing Address - Street 2:L1108.5
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1328
Mailing Address - Country:US
Mailing Address - Phone:734-927-2100
Mailing Address - Fax:
Practice Address - Street 1:8181 N WAYNE RD
Practice Address - Street 2:L1108.5
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1328
Practice Address - Country:US
Practice Address - Phone:734-927-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47030992192164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse