Provider Demographics
NPI:1760433577
Name:JEROME, JUDY L (CGNP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:L
Last Name:JEROME
Suffix:
Gender:F
Credentials:CGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N. MAIN STREET
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-1807
Mailing Address - Country:US
Mailing Address - Phone:734-222-8200
Mailing Address - Fax:734-222-8202
Practice Address - Street 1:829 N CENTER AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1595
Practice Address - Country:US
Practice Address - Phone:989-731-7870
Practice Address - Fax:989-731-7837
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120506363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4874937Medicaid
381303843OtherTAX ID
MI4704120506OtherMICHIGAN STATE LICENSE
MIMJ0967832OtherDEA
MI4704120506OtherMICHIGAN STATE LICENSE
MI4874937Medicaid