Provider Demographics
NPI:1649869488
Name:JACKSON, LEAH (CPHT)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3814
Mailing Address - Country:US
Mailing Address - Phone:734-794-0162
Mailing Address - Fax:734-794-0168
Practice Address - Street 1:2355 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3814
Practice Address - Country:US
Practice Address - Phone:734-794-0162
Practice Address - Fax:734-794-0168
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303019851183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician