Healthcare Provider Details

I. General information

NPI: 1023450350
Provider Name (Legal Business Name): JONATHAN PACKHAM OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W MEM DR
HOUGHTON MI
49931-2475
US

IV. Provider business mailing address

901 W MEM DR
HOUGHTON MI
49931-2475
US

V. Phone/Fax

Practice location:
  • Phone: 906-482-9400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201006187
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number8557
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: