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General NPI Number Information
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NPI Number | 1295207686
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Entity Type | Individual
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Provider Name | JACQUELYN GILLUM
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Gender | Female
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Dates
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Enumeration Date | 12/22/2018
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Last Update Date | 12/22/2018
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Provider Practice Location Address
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Address Line | 1132 CLAIR CIRCLE P.O.
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City | ANN ARBOR
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State | MI
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Zip | 48103-4810
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Country | US
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Telephone | 734-545-0188
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Fax |
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Provider Business Mailing Address
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Address Line | 1132 CLAIR CIR # PO
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City | ANN ARBOR
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State | MI
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Zip | 48103-3023
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Country | US
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Telephone | 734-663-9080
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Fax | 734-663-9080
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | AS810014833
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License Number State | MI
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