Basic Information
| Provider Information | |||||||||
| NPI: | 1184811499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THERING | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOSTER | ||||||||
| OtherFirstName: | JACQUELYN | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 LAPEER AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 02/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601005153 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 381908328-380 DRG | 01 | MI | CCM/CARE SOURCE | OTHER | 1027818 DRG | 01 | MI | HEALTHADVANTAGE | OTHER | 381908328408BRIDGEPO | 01 | MI | CCM/CARESOURCE | OTHER | 381908328411 OUTER | 01 | MI | CCM/CARE SOURCE | OTHER | 381908328-407 BAYSID | 01 | MI | CCM/CARE SOURCE | OTHER | 1027818 DRG | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 381908328413 ST.VIN | 01 | MI | CCM/CARE SOURCE | OTHER | 4686650 | 01 | MI | MOLINA HEALTHCARE | OTHER | 164342 | 01 | MI | GREAT LAKES HEALTH PLAN | OTHER | 381908328409 JANES | 01 | MI | CCM/CARE SOURCE | OTHER | 381908328412 COMMER | 01 | MI | CCM/CARE SOURCE | OTHER | 381908328410RUFFIN | 01 | MI | CCM/CARE SOURCE | OTHER |