Provider Demographics
NPI:1407520422
Name:NOWAK, JACQUELINE CATHERINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CATHERINE
Last Name:NOWAK
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 1:14370 BLUE SKIES ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-4931
Mailing Address - Country:US
Mailing Address - Phone:734-673-1901
Mailing Address - Fax:
Practice Address - Street 1:14370 BLUE SKIES ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-4931
Practice Address - Country:US
Practice Address - Phone:734-673-1901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202002085224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant