Provider Demographics
NPI:1225230923
Name:TICKLE, JAMIE A
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:A
Last Name:TICKLE
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 1:2800 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-7711
Mailing Address - Country:US
Mailing Address - Phone:810-388-1200
Mailing Address - Fax:
Practice Address - Street 1:3400 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:MI
Practice Address - Zip Code:48049-4318
Practice Address - Country:US
Practice Address - Phone:810-388-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant