Healthcare Provider Details

I. General information

NPI: 1700552304
Provider Name (Legal Business Name): JAMIE LYNN PLOURDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAMIE LYNN FRAHM

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 MCCARTY RD
SAGINAW MI
48603-9620
US

IV. Provider business mailing address

W175N11120 STONEWOOD DR
GERMANTOWN WI
53022-4799
US

V. Phone/Fax

Practice location:
  • Phone: 800-438-1772
  • Fax: 262-345-5562
Mailing address:
  • Phone: 800-438-1772
  • Fax: 262-345-5562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851108469
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: