Provider Demographics
NPI:1649961806
Name:JACKSON, KYRA (CMA)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14261 FENTON
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2878
Mailing Address - Country:US
Mailing Address - Phone:313-970-3572
Mailing Address - Fax:
Practice Address - Street 1:14261 FENTON
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-2878
Practice Address - Country:US
Practice Address - Phone:313-970-3572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health