Provider Demographics
NPI:1386101574
Name:JACKSON, YAMISHA (CNA)
Entity type:Individual
Prefix:MS
First Name:YAMISHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7762 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-5426
Mailing Address - Country:US
Mailing Address - Phone:313-658-6938
Mailing Address - Fax:313-473-8192
Practice Address - Street 1:11611 GRAYTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1643
Practice Address - Country:US
Practice Address - Phone:313-556-4769
Practice Address - Fax:313-473-8192
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230009497230504372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No372600000XNursing Service Related ProvidersAdult Companion