Provider Demographics
NPI:1184202749
Name:PATERNOSTER, JACQUELINE RENEE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:PATERNOSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 4 MILE RD NW APT 3B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-7314
Mailing Address - Country:US
Mailing Address - Phone:313-399-6995
Mailing Address - Fax:
Practice Address - Street 1:2399 E WALTON BLVD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-1955
Practice Address - Country:US
Practice Address - Phone:248-475-6400
Practice Address - Fax:248-475-6403
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator