Healthcare Provider Details

I. General information

NPI: 1639512791
Provider Name (Legal Business Name): JACLYN L MASCARIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PINE GROVE AVE
PORT HURON MI
48060-3511
US

IV. Provider business mailing address

PO BOX 595498
FORT GRATIOT MI
48059-5498
US

V. Phone/Fax

Practice location:
  • Phone: 810-989-3300
  • Fax:
Mailing address:
  • Phone: 810-300-4887
  • Fax: 810-985-2671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107043
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011637
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: