Provider Demographics
NPI:1780616011
Name:LOCKHART, JACQUELYN G (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:G
Last Name:LOCKHART
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:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48333-2120
Mailing Address - Country:US
Mailing Address - Phone:248-539-8446
Mailing Address - Fax:248-539-8447
Practice Address - Street 1:31800 NORTHWESTERN HWY STE 120
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1663
Practice Address - Country:US
Practice Address - Phone:248-539-8446
Practice Address - Fax:248-539-8447
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJL4301055419208100000X
OH35054104208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE77894Medicare UPIN
MI0636591Medicare ID - Type Unspecified