Healthcare Provider Details

I. General information

NPI: 1346509692
Provider Name (Legal Business Name): JACQUELINE EASTMAN YAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3271 CLEAR VISTA CT NE
GRAND RAPIDS MI
49525-9477
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-7125
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number4301111447
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: