Provider Demographics
NPI:1649151184
Name:COULTER, JACQUIS
Entity type:Individual
Prefix:MS
First Name:JACQUIS
Middle Name:
Last Name:COULTER
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 1:18048 KEYSTONE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-2327
Mailing Address - Country:US
Mailing Address - Phone:313-974-1544
Mailing Address - Fax:
Practice Address - Street 1:18048 KEYSTONE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-2327
Practice Address - Country:US
Practice Address - Phone:313-974-1544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INHHA2002606374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide