Basic Information
| Provider Information | |||||||||
| NPI: | 1952800435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABBOTT | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | ELIZABETH EFRUSY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | A-GNP-C | ||||||||
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| OtherLastName: | EFRUSY | ||||||||
| OtherFirstName: | JACLYN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882871082 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2018 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704299676 | MI | N | Nursing Service Providers | Registered Nurse | 363LA2200X | AG02180041 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 4704299676 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.