Provider Demographics
NPI:1881835460
Name:STOCKBRIDGE, JAEL (RD)
Entity type:Individual
Prefix:
First Name:JAEL
Middle Name:
Last Name:STOCKBRIDGE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1426
Mailing Address - Country:US
Mailing Address - Phone:517-647-2290
Mailing Address - Fax:
Practice Address - Street 1:2622 HEARTLAND BLVD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-8757
Practice Address - Country:US
Practice Address - Phone:616-522-0265
Practice Address - Fax:616-522-0298
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered