Provider Demographics
NPI:1801209739
Name:POLJACK, JODI L (OTRL)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:L
Last Name:POLJACK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5828 N MARSH BANK LN
Mailing Address - Street 2:APT. 101
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4700
Mailing Address - Country:US
Mailing Address - Phone:248-760-0265
Mailing Address - Fax:
Practice Address - Street 1:5828 N MARSH BANK LN
Practice Address - Street 2:APT. 101
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4700
Practice Address - Country:US
Practice Address - Phone:248-760-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002162225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist