Provider Demographics
NPI:1619685534
Name:JACKSON, KELLONTREIA LAPORCHE (A-GNP-C)
Entity type:Individual
Prefix:
First Name:KELLONTREIA
Middle Name:LAPORCHE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41800 W 11 MILE RD STE 109
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1818
Mailing Address - Country:US
Mailing Address - Phone:248-660-1220
Mailing Address - Fax:
Practice Address - Street 1:41800 W 11 MILE RD STE 109
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1818
Practice Address - Country:US
Practice Address - Phone:248-660-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN259383363LG0600X
TX1176633363LG0600X
TN36993363LG0600X
MI4704420181363LG0600X
COC-APN.0102805-C-NP363LG0600X
IAH181146363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology