Provider Demographics
NPI:1144778812
Name:PROKOP, JACQUELYN NICOLE (PA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:NICOLE
Last Name:PROKOP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:NICOLE
Other - Last Name:MEEHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:301 W WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2761
Mailing Address - Country:US
Mailing Address - Phone:989-832-0900
Mailing Address - Fax:989-633-0349
Practice Address - Street 1:301 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2761
Practice Address - Country:US
Practice Address - Phone:989-832-0900
Practice Address - Fax:989-633-0349
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant