Provider Demographics
NPI:1891482212
Name:BRIGHAM, JODIE ANN
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:ANN
Last Name:BRIGHAM
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 1:11590 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48850-9708
Mailing Address - Country:US
Mailing Address - Phone:989-560-9733
Mailing Address - Fax:
Practice Address - Street 1:1380 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EDMORE
Practice Address - State:MI
Practice Address - Zip Code:48829-8413
Practice Address - Country:US
Practice Address - Phone:989-560-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM590407641311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home