Healthcare Provider Details

I. General information

NPI: 1467096594
Provider Name (Legal Business Name): JACLYN N THWEATT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 10/18/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENESYS PKWY
GRAND BLANC MI
48439-8065
US

IV. Provider business mailing address

7156 MANOR LN
FOWLERVILLE MI
48836-9796
US

V. Phone/Fax

Practice location:
  • Phone: 810-610-9618
  • Fax:
Mailing address:
  • Phone: 248-880-2876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN.468432
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704295540
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: