Provider Demographics
NPI:1316702384
Name:JACKSON, MARCUS DANGELO
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:DANGELO
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 1:2677 MONTEREY ST APT 1W
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-1140
Mailing Address - Country:US
Mailing Address - Phone:248-228-0579
Mailing Address - Fax:
Practice Address - Street 1:3290 W BIG BEAVER RD STE 510
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-2917
Practice Address - Country:US
Practice Address - Phone:734-513-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician