Provider Demographics
NPI:1063000545
Name:RILEY, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:ONSTWEDDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1083 BEACONSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1346
Mailing Address - Country:US
Mailing Address - Phone:313-550-3353
Mailing Address - Fax:
Practice Address - Street 1:2050 N HAGGERTY RD STE 200
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3796
Practice Address - Country:US
Practice Address - Phone:313-550-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704347010363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner