Individual
DR. RODGER DALE JACKSON JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DO, MPH
Contact information
Practice address
6777 W MAPLE RD, DEPARTMENT OF EMERGENCY MEDICINE, WEST BLOOMFIELD, MI 48322-3013
(313) 614-2186
Mailing address
6777 W MAPLE RD, DEPARTMENT OF EMERGENCY MEDICINE, WEST BLOOMFIELD, MI 48322-3013
(313) 614-2186
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
5101016798
MI
207R00000X
Internal Medicine Physician
5101016798
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5101016798
LICENSE
MI
01
—
5315026355
CONTROLLED SUBSTANCE LIC
MI
Enumeration date
03/08/2007
Last updated
01/22/2013
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