Provider Demographics
NPI:1093134348
Name:JACKSON HEALTH SERVICES
Entity type:Organization
Organization Name:JACKSON HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON-HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:313-831-8805
Mailing Address - Street 1:4727 SAINT ANTOINE ST
Mailing Address - Street 2:STE 202
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1461
Mailing Address - Country:US
Mailing Address - Phone:313-831-8805
Mailing Address - Fax:313-832-8206
Practice Address - Street 1:4727 SAINT ANTOINE ST
Practice Address - Street 2:STE 202
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1461
Practice Address - Country:US
Practice Address - Phone:313-831-8805
Practice Address - Fax:313-832-8206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4180604Medicaid
MI4180604Medicaid