Provider Demographics
NPI:1508390105
Name:PAGE, JACQUELYN LYNN (CPHT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:LYNN
Last Name:PAGE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1200 N WEST AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2179
Mailing Address - Country:US
Mailing Address - Phone:517-789-8579
Mailing Address - Fax:517-768-0717
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-789-8579
Practice Address - Fax:517-768-0717
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5303007913183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician