Provider Demographics
NPI:1477950095
Name:ANDERSON, JACLYN NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DRIVE
Mailing Address - Street 2:J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:5333 MCAULEY DRIVE
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-3971
Practice Address - Fax:734-887-8941
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2024-01-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601007235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant