Provider Demographics
NPI:1811941206
Name:GOVIER, JACKALYN M (DO)
Entity type:Individual
Prefix:
First Name:JACKALYN
Middle Name:M
Last Name:GOVIER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACKALYN
Other - Middle Name:M
Other - Last Name:MACKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2218 OLD US 27 N
Mailing Address - Street 2:
Mailing Address - City:TEKONSHA
Mailing Address - State:MI
Mailing Address - Zip Code:49092
Mailing Address - Country:US
Mailing Address - Phone:517-767-4038
Mailing Address - Fax:517-767-3427
Practice Address - Street 1:2218 OLD US 27 N
Practice Address - Street 2:
Practice Address - City:TEKONSHA
Practice Address - State:MI
Practice Address - Zip Code:49092
Practice Address - Country:US
Practice Address - Phone:517-767-4038
Practice Address - Fax:517-767-3427
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N79630Medicare PIN
MI233917Medicare PIN
MI0A37669Medicare PIN
MI233916Medicare PIN