Healthcare Provider Details

I. General information

NPI: 1801378161
Provider Name (Legal Business Name): JOANNE MARIE ICKES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 W NORTH ST
JACKSON MI
49202-3313
US

IV. Provider business mailing address

725 CAPE COD
SOUTH LYON MI
48178-1346
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-3250
  • Fax:
Mailing address:
  • Phone: 248-345-6784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: