Provider Demographics
NPI:1871521542
Name:JACKSON COMMUNITY AMBULANCE INC.
Entity type:Organization
Organization Name:JACKSON COMMUNITY AMBULANCE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-477-6262
Mailing Address - Street 1:1200 STATE CIR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1691
Mailing Address - Country:US
Mailing Address - Phone:734-971-4733
Mailing Address - Fax:734-477-6786
Practice Address - Street 1:1200 STATE CIR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1691
Practice Address - Country:US
Practice Address - Phone:734-971-4733
Practice Address - Fax:734-477-6786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI381013341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI183319100Medicaid
MI590H10003OtherBLUE CROSS BLUE SHIELD
MI590H10003OtherBLUE CROSS BLUE SHIELD