Provider Demographics
NPI:1659857365
Name:SIDES, JODI JEAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:JEAN
Last Name:SIDES
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 1:3724 SENEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-2709
Mailing Address - Country:US
Mailing Address - Phone:248-420-0607
Mailing Address - Fax:
Practice Address - Street 1:585 E FLINT ST
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-3209
Practice Address - Country:US
Practice Address - Phone:248-693-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001005225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist