Provider Demographics
NPI:1992371702
Name:WEBER, JACLYN (PA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:WEBER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16825 ABBY CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-4303
Mailing Address - Country:US
Mailing Address - Phone:248-444-9097
Mailing Address - Fax:
Practice Address - Street 1:17901 HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:MI
Practice Address - Zip Code:48164-3200
Practice Address - Country:US
Practice Address - Phone:734-315-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant