Provider Demographics
NPI:1356827422
Name:WEST, JACLYNN (BS, QIDP)
Entity Type:Individual
Prefix:
First Name:JACLYNN
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:BS, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9681
Mailing Address - Country:US
Mailing Address - Phone:989-362-8636
Mailing Address - Fax:
Practice Address - Street 1:1199 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9681
Practice Address - Country:US
Practice Address - Phone:989-362-8636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator