Healthcare Provider Details

I. General information

NPI: 1427535202
Provider Name (Legal Business Name): JEDD JACK AUDRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W CHISHOLM ST
ALPENA MI
49707-1401
US

IV. Provider business mailing address

4000 WELLNESS DR
MIDLAND MI
48670-1000
US

V. Phone/Fax

Practice location:
  • Phone: 989-356-8060
  • Fax: 989-356-7794
Mailing address:
  • Phone: 844-832-1956
  • Fax: 989-633-5241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number4301507428
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301507428
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number4301507428
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: