Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 5202005667 | MI |
NPI | 1871049684 |
---|---|
Provider Name | Monique Jackson |
First Address | Flint, MI 48532-2271 |
Second Address | Detroit, MI 48219 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2016 |
Last Update Date | 31/08/2016 |