Healthcare Provider Details

I. General information

NPI: 1962109793
Provider Name (Legal Business Name): JAIDE KELLI BAMMER OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/28/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LAURENCE AVE
JACKSON MI
49202-2979
US

IV. Provider business mailing address

1001 LAURENCE AVE
JACKSON MI
49202-2979
US

V. Phone/Fax

Practice location:
  • Phone: 517-750-4777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201013249
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: