Healthcare Provider Details

I. General information

NPI: 1164505004
Provider Name (Legal Business Name): JODI LYNN DEWHIRST LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 CHILLION DR
CRESTLINE CA
92325
US

IV. Provider business mailing address

919 CHILLION DR PO BOX 4035
CRESTLINE CA
92325
US

V. Phone/Fax

Practice location:
  • Phone: 909-338-2483
  • Fax:
Mailing address:
  • Phone: 909-338-2483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number0057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: