Provider Demographics
NPI:1568999332
Name:COSGROVE, JACQUELYN LEE (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LEE
Last Name:COSGROVE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:COSGROVE MALLEIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:2820 E BELTLINE LN NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9432
Mailing Address - Country:US
Mailing Address - Phone:616-363-5413
Mailing Address - Fax:616-363-4211
Practice Address - Street 1:2820 E BELTLINE LN NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9432
Practice Address - Country:US
Practice Address - Phone:616-363-5413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005682152W00000X
WAOD60861196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist