Provider Demographics
NPI:1316359854
Name:METZ, JACQUELINE SUSAN (DO)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:SUSAN
Last Name:METZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:SUSAN
Other - Last Name:LAROUERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5500 AUTO CLUB DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2779
Mailing Address - Country:US
Mailing Address - Phone:313-425-4700
Mailing Address - Fax:313-425-4701
Practice Address - Street 1:5500 AUTO CLUB DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2779
Practice Address - Country:US
Practice Address - Phone:313-425-4700
Practice Address - Fax:313-425-4701
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021108390200000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program