Provider Demographics
NPI:1629069646
Name:MCCLOSKEY, JACALYN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACALYN
Middle Name:A
Last Name:MCCLOSKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35046 WOODWARD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-0932
Mailing Address - Country:US
Mailing Address - Phone:248-647-9860
Mailing Address - Fax:248-647-9864
Practice Address - Street 1:35046 WOODWARD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-0932
Practice Address - Country:US
Practice Address - Phone:248-647-9860
Practice Address - Fax:248-647-9864
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051514207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OF36482004Medicare ID - Type Unspecified
E90671Medicare UPIN