Healthcare Provider Details

I. General information

NPI: 1013897412
Provider Name (Legal Business Name): JODI BANASZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E MAIN ST STE 115
MIDLAND MI
48640-5488
US

IV. Provider business mailing address

728 AVONDALE ST
BAY CITY MI
48708-5587
US

V. Phone/Fax

Practice location:
  • Phone: 989-486-1457
  • Fax:
Mailing address:
  • Phone: 989-316-5751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3502013328
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: