Provider Demographics
NPI:1003376260
Name:WALTERS, JODEAN RUTH (OTA)
Entity Type:Individual
Prefix:
First Name:JODEAN
Middle Name:RUTH
Last Name:WALTERS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33533 W 12 MILE RD STE 290
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-5635
Mailing Address - Country:US
Mailing Address - Phone:248-865-1177
Mailing Address - Fax:
Practice Address - Street 1:4322 MACKINAW RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3110
Practice Address - Country:US
Practice Address - Phone:248-865-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2019-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008384224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant