Active NPI
Edna Ruth Jackson, RN
- Administrator Registered Nurse
- Detroit, MI
National Provider Identifier
1114097870
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Administrator Registered Nurse
- License
- 4704118498
- Practice address
- 2395 W Grand Blvd
Detroit, MI 48208-1210 - Phone
- (313) 897-2061
- NPI assigned
- Nov 9, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Administrator Registered Nurse | 163WA2000X | 4704118498 | MI | Primary |
Addresses
Primary practice location
2395 W Grand Blvd
Detroit, MI 48208-1210
Mailing address
18001 Saint Marys St
Detroit, MI 48235-3176
Phone (313) 272-4034
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Nurse
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4704118498 | MI | MD | Administrator Registered Nurse |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Detroit Health Care for the Homeless | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Federally Qualified Health Center (FQHC)
- Warren, MI
- NPI 1043103989
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1163030400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1114097870",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "18001 SAINT MARYS ST",
"city": "DETROIT",
"state": "MI",
"postal_code": "482353176",
"telephone_number": "313-272-4034"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2395 W GRAND BLVD",
"city": "DETROIT",
"state": "MI",
"postal_code": "482081210",
"telephone_number": "313-897-2061"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "EDNA",
"middle_name": "RUTH",
"name_prefix": "Mrs.",
"credential": "RN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-11-09",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "163WA2000X",
"taxonomy_group": "",
"desc": "Registered Nurse, Administrator",
"state": "MI",
"license": "4704118498",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Detroit, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.