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General NPI Number Information
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NPI Number | 1700289543
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Entity Type | Individual
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Provider Name | JACLYN CAROL HOUSE MSN, FNP-BC, RN
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Gender | Female
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Dates
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Enumeration Date | 10/08/2014
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Last Update Date | 01/08/2015
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Provider Practice Location Address
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Address Line | 3990 JOHN R ST
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City | DETROIT
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State | MI
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Zip | 48201-2018
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Country | US
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Telephone | 313-745-2879
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Fax |
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Provider Business Mailing Address
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Address Line | 13117 W 11 MILE RD
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City | HUNTINGTON WOODS
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State | MI
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Zip | 48070-1009
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Country | US
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Telephone | 248-259-3075
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4704276550
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 4704276550
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License Number State | MI
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