Provider Demographics
NPI:1578044962
Name:PHILLION, JACLYN MAE (ACAGNP)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:MAE
Last Name:PHILLION
Suffix:
Gender:F
Credentials:ACAGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23550 PARK ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2592
Mailing Address - Country:US
Mailing Address - Phone:313-730-0500
Mailing Address - Fax:
Practice Address - Street 1:23550 PARK ST STE 100
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2592
Practice Address - Country:US
Practice Address - Phone:313-730-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704290482363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care