Basic Information
| Provider Information | |||||||||
| NPI: | 1184202749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATERNOSTER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 980 4 MILE RD NW APT 3B | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495447314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133996995 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2399 E WALTON BLVD | ||||||||
| Address2: | |||||||||
| City: | AUBURN HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483261955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484756400 | ||||||||
| FaxNumber: | 2484756403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2021 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.