Provider Demographics
NPI:1811456965
Name:HUNT, JACLYN LEE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:LEE
Last Name:HUNT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 S SHORE DR SE APT 102
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-0907
Mailing Address - Country:US
Mailing Address - Phone:734-788-3183
Mailing Address - Fax:
Practice Address - Street 1:2111 S SHORE DR SE APT 102
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-0907
Practice Address - Country:US
Practice Address - Phone:734-788-3183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703115744164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse