Basic Information
| Provider Information | |||||||||
| NPI: | 1750516191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACLAIR | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACOBSON | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | JOY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1560 E SHERMAN BLVD STE 240 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316723883 | ||||||||
| FaxNumber: | 2316723973 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E SHERMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316723883 | ||||||||
| FaxNumber: | 2316723973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2009 | ||||||||
| LastUpdateDate: | 04/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101018145 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 5101018145 | MI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.