Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175L00000X | Homeopath | 8947370 | MI |
NPI | 1376927442 |
---|---|
Provider Name | Rena Adell Jackson |
First Address | Detroit, MI 48227 |
Second Address | Detroit, MI 48227 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2015 |
Last Update Date | 17/07/2015 |