Basic Information
| Provider Information | |||||||||
| NPI: | 1073165692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ROSALIND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3040 W GRAND BLVD STE L450 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482026014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483726800 | ||||||||
| FaxNumber: | 2483551402 | ||||||||
| Practice Location | |||||||||
| Address1: | 3040 W GRAND BLVD STE L450 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482026014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134566830 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2019 | ||||||||
| LastUpdateDate: | 07/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 6801089565 | MI | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.