Healthcare Provider Details

I. General information

NPI: 1174922884
Provider Name (Legal Business Name): JEREMY KUDZIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25401 HARPER AVE STE 2
SAINT CLAIR SHORES MI
48081-2248
US

IV. Provider business mailing address

42383 GARFIELD RD UNIT 381131
CLINTON TOWNSHIP MI
48038-7737
US

V. Phone/Fax

Practice location:
  • Phone: 586-469-6912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704307001
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704307001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: