Provider Demographics
NPI:1366508822
Name:JACQUEMIN, REBECCA A (OD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:JACQUEMIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:DIGNUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:11971 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-9610
Mailing Address - Country:US
Mailing Address - Phone:616-395-0606
Mailing Address - Fax:616-395-0070
Practice Address - Street 1:11971 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9610
Practice Address - Country:US
Practice Address - Phone:616-395-0606
Practice Address - Fax:616-395-0070
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004404152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI204829649OtherTAX ID
MI5175716Medicaid
MI5175716Medicaid
MIP32620005Medicare PIN
MI0P32620Medicare PIN