Provider Demographics
NPI:1205584372
Name:CARNAHAN, JACLYN MARIE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:CARNAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9671 HENDERSON RD
Mailing Address - Street 2:
Mailing Address - City:CORUNNA
Mailing Address - State:MI
Mailing Address - Zip Code:48817-9793
Mailing Address - Country:US
Mailing Address - Phone:989-413-3886
Mailing Address - Fax:
Practice Address - Street 1:8531 E LANSING RD
Practice Address - Street 2:
Practice Address - City:DURAND
Practice Address - State:MI
Practice Address - Zip Code:48429-1072
Practice Address - Country:US
Practice Address - Phone:989-288-3101
Practice Address - Fax:989-288-0017
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303009757183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5303009757OtherLARA