Provider Demographics
NPI:1043985930
Name:JACKSON, KATHARINE MAEVE
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:MAEVE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11132 PLEASANT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DELTON
Mailing Address - State:MI
Mailing Address - Zip Code:49046-9560
Mailing Address - Country:US
Mailing Address - Phone:269-366-6661
Mailing Address - Fax:
Practice Address - Street 1:5500 ARMSTRONG RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-7314
Practice Address - Country:US
Practice Address - Phone:269-966-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26439446390200000X
MI09162020175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program