Provider Demographics
NPI:1295207686
Name:GILLUM, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:GILLUM
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 1:1132 CLAIR CIR # PO
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3023
Mailing Address - Country:US
Mailing Address - Phone:734-663-9080
Mailing Address - Fax:734-663-9080
Practice Address - Street 1:1132 CLAIR CIRCLE
Practice Address - Street 2:P.O.
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-4810
Practice Address - Country:US
Practice Address - Phone:734-545-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS810014833172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker