Provider Demographics
NPI:1225897663
Name:CODDINGTON, JESSICA YVONNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:YVONNE
Last Name:CODDINGTON
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 1:11210 DODGE RD
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9739
Mailing Address - Country:US
Mailing Address - Phone:810-834-5340
Mailing Address - Fax:
Practice Address - Street 1:204 E NEPESSING ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2316
Practice Address - Country:US
Practice Address - Phone:810-356-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501015908225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist