Provider Demographics
NPI:1558931048
Name:DEJAEGHERE, JODI LYNNE
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNNE
Last Name:DEJAEGHERE
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 1:26120 CULVER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3330
Mailing Address - Country:US
Mailing Address - Phone:248-860-6127
Mailing Address - Fax:
Practice Address - Street 1:36485 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1132
Practice Address - Country:US
Practice Address - Phone:586-791-0738
Practice Address - Fax:586-791-3240
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303008702183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician