Healthcare Provider Details

I. General information

NPI: 1609169184
Provider Name (Legal Business Name): GRETCHEN MARIE JAKUBIAK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15474 HAGGERTY RD
NORTHVILLE MI
48170-4890
US

IV. Provider business mailing address

901 MCCLINTOCK DR SUITE 202
BURR RIDGE IL
60527-0871
US

V. Phone/Fax

Practice location:
  • Phone: 734-335-6103
  • Fax: 734-404-5317
Mailing address:
  • Phone: 888-220-6432
  • Fax: 630-654-4253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704215872
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: