Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RE0101X | Endocrinologist (Diabetes Doctor) | 4301043930 | MI |
NPI | 1023153178 |
---|---|
Provider Name | Hershel Jackson |
First Address | Southfield, MI 48075-3760 |
Second Address | Detroit, MI 48201-2018 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2007 |
Last Update Date | 08/07/2007 |