Healthcare Provider Details

I. General information

NPI: 1598348153
Provider Name (Legal Business Name): JORDAN WYETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W GARFIELD AVE
CHARLEVOIX MI
49720-1631
US

IV. Provider business mailing address

3816 LORRAINE DR
PETOSKEY MI
49770-8640
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-6523
  • Fax:
Mailing address:
  • Phone: 989-233-4085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704305091
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: