Provider Demographics
NPI:1306800933
Name:BALON, JACQUELINE (NP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BALON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 120070
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49528-0102
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:30055 NORTHWESTERN HWY
Practice Address - Street 2:STE L50
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3230
Practice Address - Country:US
Practice Address - Phone:248-626-8200
Practice Address - Fax:248-737-9287
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704100757363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4362714Medicaid
MI13834OtherMCARE
MI4790050Medicaid
0866685OtherBCBSM
P30273OtherHEALTH ALLIANCE PLAN
MI4362714Medicaid
P30273Medicare UPIN