Healthcare Provider Details

I. General information

NPI: 1124799739
Provider Name (Legal Business Name): JACQUELINE ANN CISTERNINO CPSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 SUMMIT DR
WATERFORD MI
48328-3364
US

IV. Provider business mailing address

24230 KARIM BLVD
NOVI MI
48375-2960
US

V. Phone/Fax

Practice location:
  • Phone: 248-724-6185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: