Provider Demographics
NPI:1972586113
Name:TAYLOR, JACQUELINE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:L
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LOUISE
Other - Last Name:AURELIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1435 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2653
Mailing Address - Country:US
Mailing Address - Phone:248-543-2229
Mailing Address - Fax:248-545-1023
Practice Address - Street 1:1435 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2653
Practice Address - Country:US
Practice Address - Phone:248-543-2229
Practice Address - Fax:248-545-1023
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076014207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I11442Medicare UPIN
MIN34980003Medicare PIN