Provider Demographics
NPI:1699209205
Name:WACHOWIAK, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:WACHOWIAK
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 1:36 LAURIE CT
Mailing Address - Street 2:LOT 129
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-9409
Mailing Address - Country:US
Mailing Address - Phone:989-894-0021
Mailing Address - Fax:
Practice Address - Street 1:3007 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4555
Practice Address - Country:US
Practice Address - Phone:989-633-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703078235164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse