Basic Information
| Provider Information | |||||||||
| NPI: | 1073081766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMILTON | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LENNOX | ||||||||
| OtherFirstName: | JACQUELYN | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 TOWN CENTER DR STE 203 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480841744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221859 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 44201 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480851117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488985000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2018 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704182047 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.