MEDICARE: JACLYN ESTHER MICHNIAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704286575	MI

General Provider Information

NPI Number	:	1801447768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN ESTHER MICHNIAK

Provider Business Mailing Address
First Line	:	11401 N RUSHTON RD
Second Line	:
City	:	SOUTH LYON
State	:	MI
Zip	:	48178-9123
Country	:	US
Telephone Number	:	248-996-0421
Fax Number	:

Provider Business Practice Location Address
First Line	:	11401 N RUSHTON RD
Second Line	:
City	:	SOUTH LYON
State	:	MI
Zip	:	48178-9123
Country	:	US
Telephone Number	:	248-996-0421
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	04/21/2025

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