Individual
KIYYO SHIRESE JACKSON I
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2925 RUSSELL ST, DETROIT, MI 48207-4825
(313) 396-5300
(313) 396-5353
Mailing address
2925 RUSSELL ST, DETROIT, MI 48207-4825
(313) 396-5300
(313) 396-5353
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
6803086048
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6803086048
—
MI
Enumeration date
07/22/2014
Last updated
07/22/2014
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