Provider Demographics
NPI:1417416884
Name:WASIK, JODI MARIE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:MARIE
Last Name:WASIK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1801
Mailing Address - Country:US
Mailing Address - Phone:734-455-0510
Mailing Address - Fax:
Practice Address - Street 1:105 N HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1801
Practice Address - Country:US
Practice Address - Phone:734-455-0510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003403225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist