Provider Demographics
NPI:1043708159
Name:CHAMPLIN, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:CHAMPLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35511 LUCERNE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2744
Mailing Address - Country:US
Mailing Address - Phone:586-242-6774
Mailing Address - Fax:
Practice Address - Street 1:35511 LUCERNE ST
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2744
Practice Address - Country:US
Practice Address - Phone:586-242-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703119052164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse