Provider Demographics
NPI:1235997198
Name:MCLAURIN, JESTINE
Entity Type:Individual
Prefix:
First Name:JESTINE
Middle Name:
Last Name:MCLAURIN
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 1:2647 BURLINGAME ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-1431
Mailing Address - Country:US
Mailing Address - Phone:313-213-6909
Mailing Address - Fax:
Practice Address - Street 1:3605 ASH ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2931
Practice Address - Country:US
Practice Address - Phone:313-213-6909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home