Healthcare Provider Details

I. General information

NPI: 1366940496
Provider Name (Legal Business Name): JACQUELINE N DONOVAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W 17530 MAIN ST
CURTIS MI
49820
US

IV. Provider business mailing address

502 W HARRIE ST
NEWBERRY MI
49868
US

V. Phone/Fax

Practice location:
  • Phone: 906-586-3300
  • Fax:
Mailing address:
  • Phone: 906-293-9200
  • Fax: 906-586-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704282026
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: