Provider Demographics
NPI:1689438574
Name:KIROUAC, JACQUELINE (MSN, AGNP-C, APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KIROUAC
Suffix:
Gender:F
Credentials:MSN, AGNP-C, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 CARSONS CV
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-1865
Mailing Address - Country:US
Mailing Address - Phone:248-881-4287
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704341154163WM0705X
MIAG11210087363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical