Provider Demographics
NPI:1093019747
Name:STOCKOSKI, JACLYN M (CRNA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:STOCKOSKI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:M
Other - Last Name:MATESOWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:BEAUMONT PHYSICIAN PARTNERS PAYOR ENROLLMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-7784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253212367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430F364420OtherBCBSM
MI1093019747Medicaid
MI0F36442460Medicare PIN