Provider Demographics
NPI:1952468720
Name:CHURCH, JAIMIE LYNN (OD)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:LYNN
Last Name:CHURCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JAIMIE
Other - Middle Name:LYNN
Other - Last Name:BEHRENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2583 LAKE PINE DR
Mailing Address - Street 2:#13
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8200
Mailing Address - Country:US
Mailing Address - Phone:616-240-1301
Mailing Address - Fax:
Practice Address - Street 1:1860 PIPESTONE RD
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2304
Practice Address - Country:US
Practice Address - Phone:616-927-5868
Practice Address - Fax:616-934-9485
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004309152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist