Individual
MR. CORNELL LEE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1852 W GRAND BLVD, DETROIT, MI 48208-1006
(313) 894-8444
(313) 894-5542
Mailing address
1852 W GRAND BLVD, DETROIT, MI 48208-1006
(313) 894-8444
(313) 894-5542
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
381917278
—
MI
Enumeration date
02/04/2013
Last updated
02/04/2013
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