Provider Demographics
NPI:1134549751
Name:JACKSON, AMELIA
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23636 MICHIGAN AVE # 487
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1910
Mailing Address - Country:US
Mailing Address - Phone:419-788-1199
Mailing Address - Fax:313-914-5853
Practice Address - Street 1:23636 MICHIGAN AVE # 487
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1910
Practice Address - Country:US
Practice Address - Phone:419-788-1199
Practice Address - Fax:313-914-5853
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIE4197J372600000X, 374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide