| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology - Neurology |
| Location | 205 N. East Ave, Jackson, Michigan |
| Authorized Official Name and Position | Mark Smith (SVP) |
| Authorized Official Contact | 5172056407 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 67000 Department 272801 Detroit MI 48267 Ph: (517) 841-7843 | 205 N. East Ave Jackson MI 49201 Ph: (517) 841-7843 |
| NPI Number | 1235676446 |
|---|---|
| Provider Enumeration Date | 01/25/2017 |
| Last Update Date | 03/06/2024 |
| Certification Date | 03/06/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1235676446 | NPI | - | NPPES |
| 1760437826 | Medicaid | MI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084N0400X | Psychiatry & Neurology - Neurology | 1060000044 (Michigan) | Primary |
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