Provider Demographics
NPI:1346499639
Name:WILFONG, JODY LYNN
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:LYNN
Last Name:WILFONG
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JODY
Other - Middle Name:LYNN
Other - Last Name:PRIESTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT-BC,NMT
Mailing Address - Street 1:15283 LONGFELLOW DR
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MI
Mailing Address - Zip Code:48418-8846
Mailing Address - Country:US
Mailing Address - Phone:810-266-4045
Mailing Address - Fax:
Practice Address - Street 1:15283 LONGFELLOW DR
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:MI
Practice Address - Zip Code:48418-8846
Practice Address - Country:US
Practice Address - Phone:810-266-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI06257225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist