Provider Demographics
NPI:1205346749
Name:FIRSTEN, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:FIRSTEN
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 1:113B E LONG LAKE RD STE B
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-5524
Mailing Address - Country:US
Mailing Address - Phone:248-435-6811
Mailing Address - Fax:248-435-6855
Practice Address - Street 1:113B E LONG LAKE RD STE B
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-5524
Practice Address - Country:US
Practice Address - Phone:248-435-6811
Practice Address - Fax:248-435-6855
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501006276237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist