Healthcare Provider Details

I. General information

NPI: 1346839586
Provider Name (Legal Business Name): JACLYN PARKER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E MICHIGAN AVE
GRAYLING MI
49738-1312
US

IV. Provider business mailing address

1100 E MICHIGAN AVE
GRAYLING MI
49738-1312
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-5461
  • Fax:
Mailing address:
  • Phone: 248-821-1084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704307936
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: