Provider Demographics
NPI:1477057248
Name:SUTLIFF, JALISSA MARIE
Entity Type:Individual
Prefix:
First Name:JALISSA
Middle Name:MARIE
Last Name:SUTLIFF
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 1:715 DIVISION RD
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-3915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11410 E LENNON RD
Practice Address - Street 2:
Practice Address - City:LENNON
Practice Address - State:MI
Practice Address - Zip Code:48449-9666
Practice Address - Country:US
Practice Address - Phone:810-621-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant