Provider Demographics
NPI:1801447768
Name:MICHNIAK, JACLYN ESTHER
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ESTHER
Last Name:MICHNIAK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 N RUSHTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9123
Mailing Address - Country:US
Mailing Address - Phone:248-996-0421
Mailing Address - Fax:
Practice Address - Street 1:11401 N RUSHTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9123
Practice Address - Country:US
Practice Address - Phone:248-996-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286575363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily