Provider Demographics
NPI:1336109438
Name:MACKNIS, JACQUELINE K (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:K
Last Name:MACKNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:400 FSC - PCS
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6769
Mailing Address - Country:US
Mailing Address - Phone:248-898-5969
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6769
Practice Address - Country:US
Practice Address - Phone:248-423-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067705207ZP0101X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI220F349850OtherBCBSM
MI4634690Medicaid
MIH70036Medicare UPIN
MI4634690Medicaid