Provider Demographics
NPI:1114145133
Name:LISTON-CRANDALL, JACLYN SUMMER (MD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:SUMMER
Last Name:LISTON-CRANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2218 US HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:TEKONSHA
Mailing Address - State:MI
Mailing Address - Zip Code:49092-9261
Mailing Address - Country:US
Mailing Address - Phone:517-767-4038
Mailing Address - Fax:517-767-3427
Practice Address - Street 1:2218 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:TEKONSHA
Practice Address - State:MI
Practice Address - Zip Code:49092-9261
Practice Address - Country:US
Practice Address - Phone:517-767-4038
Practice Address - Fax:517-767-3427
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A37669Medicare PIN