Provider Demographics
NPI:1043076599
Name:LODES, JEAN M (CHW)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:LODES
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9431 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:MI
Mailing Address - Zip Code:49421-9581
Mailing Address - Country:US
Mailing Address - Phone:231-450-3897
Mailing Address - Fax:
Practice Address - Street 1:9431 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:MI
Practice Address - Zip Code:49421-9581
Practice Address - Country:US
Practice Address - Phone:231-450-3897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker