Provider Demographics
NPI:1386970739
Name:KOURNOIAN, JACLYN SUZETTE (NP-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:SUZETTE
Last Name:KOURNOIAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:SUZETTE
Other - Last Name:BOROWIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:42577 GREYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-2990
Mailing Address - Country:US
Mailing Address - Phone:586-480-9383
Mailing Address - Fax:
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:586-690-9062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704234791363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily