Provider Demographics
NPI:1831204106
Name:STICKNEY, JEFFREY ALAN (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:STICKNEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 W WILLIS RD
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-1750
Mailing Address - Country:US
Mailing Address - Phone:517-902-5234
Mailing Address - Fax:
Practice Address - Street 1:85 W WILLIS RD
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1750
Practice Address - Country:US
Practice Address - Phone:517-902-5234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006955207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI29050611Medicaid
MION95690Medicare ID - Type Unspecified
MIE37575Medicare UPIN