Healthcare Provider Details

I. General information

NPI: 1639894264
Provider Name (Legal Business Name): JAMIE LYNN STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 DIANA ST
LUDINGTON MI
49431-1987
US

IV. Provider business mailing address

920 DIANA ST
LUDINGTON MI
49431-1987
US

V. Phone/Fax

Practice location:
  • Phone: 231-845-6294
  • Fax:
Mailing address:
  • Phone: 231-845-6294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number69928
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: