Provider Demographics
NPI:1285668863
Name:SCARBROUGH, JACQUELINE MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:SCARBROUGH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 MELVIN RD
Mailing Address - Street 2:
Mailing Address - City:PECK
Mailing Address - State:MI
Mailing Address - Zip Code:48466-9777
Mailing Address - Country:US
Mailing Address - Phone:810-378-5232
Mailing Address - Fax:
Practice Address - Street 1:5590 MAIN ST.
Practice Address - Street 2:SUITE 1
Practice Address - City:LEXINGTON
Practice Address - State:MI
Practice Address - Zip Code:48450
Practice Address - Country:US
Practice Address - Phone:810-359-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004203152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIV06719Medicare UPIN