Provider Demographics
NPI:1811056765
Name:MICALLEF, JODI AN (RD,CDE)
Entity type:Individual
Prefix:MRS
First Name:JODI AN
Middle Name:
Last Name:MICALLEF
Suffix:
Gender:F
Credentials:RD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3990 JOHN R ST
Mailing Address - Street 2:8 BRUSH, ROOM 8805
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2018
Mailing Address - Country:US
Mailing Address - Phone:313-745-9361
Mailing Address - Fax:313-966-9585
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:8 BRUSH, ROOM 8805
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-745-9361
Practice Address - Fax:313-966-9585
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION74700Medicare PIN