Provider Demographics
NPI:1346763737
Name:JACKSON, DAIRRUS M
Entity type:Individual
Prefix:MR
First Name:DAIRRUS
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15193 HALLER ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-4017
Mailing Address - Country:US
Mailing Address - Phone:248-750-4828
Mailing Address - Fax:
Practice Address - Street 1:12007 LINWOOD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-1107
Practice Address - Country:US
Practice Address - Phone:313-867-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician