Provider Demographics
NPI:1427808401
Name:JACKSON, YVONNE (RN)
Entity type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19178 HUBBELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1927
Mailing Address - Country:US
Mailing Address - Phone:313-743-7295
Mailing Address - Fax:
Practice Address - Street 1:19178 HUBBELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1927
Practice Address - Country:US
Practice Address - Phone:313-743-7295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47044381419163WC2100X, 163WH0200X, 163WI0500X, 163WI0600X, 163WW0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC2100XNursing Service ProvidersRegistered NurseContinence Care
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WI0600XNursing Service ProvidersRegistered NurseInfection Control
No163WW0000XNursing Service ProvidersRegistered NurseWound Care