Healthcare Provider Details

I. General information

NPI: 1821082306
Provider Name (Legal Business Name): BRIDGETTE L JERRELS D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15488 WILDEMERE ST
DETROIT MI
48238-1438
US

IV. Provider business mailing address

PO BOX 20045
FERNDALE MI
48220-0045
US

V. Phone/Fax

Practice location:
  • Phone: 313-863-5783
  • Fax:
Mailing address:
  • Phone: 313-863-5783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001553
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: