Healthcare Provider Details

I. General information

NPI: 1508311218
Provider Name (Legal Business Name): JODY GARCIA-FOWLKES CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W WACKERLY ST STE 3625
MIDLAND MI
48640-4715
US

IV. Provider business mailing address

518 CHARING CROSS DR
GRAND BLANC MI
48439-1540
US

V. Phone/Fax

Practice location:
  • Phone: 989-832-4202
  • Fax:
Mailing address:
  • Phone: 248-308-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016828
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6351004625
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number6351004625
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6351004625
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6351004625
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: