Provider Demographics
NPI:1427612480
Name:JACKSON, CHRISTOPHER JOHN (AGACNP)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8921 HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3518
Mailing Address - Country:US
Mailing Address - Phone:313-815-6047
Mailing Address - Fax:
Practice Address - Street 1:8921 HARVEY ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3518
Practice Address - Country:US
Practice Address - Phone:313-815-6047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704297208363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty