Healthcare Provider Details

I. General information

NPI: 1205740362
Provider Name (Legal Business Name): JESSICA SHIVLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 COBB ST
CADILLAC MI
49601-2588
US

IV. Provider business mailing address

1615 MICHIGAN AVE
BALDWIN MI
49304-7984
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-6505
  • Fax:
Mailing address:
  • Phone: 231-745-5051
  • Fax: 231-745-0412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902020547
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: