Provider Demographics
NPI:1639214844
Name:WADGE, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:WADGE
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 1:601 S WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-1109
Mailing Address - Country:US
Mailing Address - Phone:906-779-1880
Mailing Address - Fax:906-779-0818
Practice Address - Street 1:601 S WESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-1109
Practice Address - Country:US
Practice Address - Phone:906-779-1880
Practice Address - Fax:906-779-0818
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B20009OtherBLUE CROSS BLUE SHIELD
MI0B20009OtherBLUE CROSS BLUE SHIELD