Healthcare Provider Details

I. General information

NPI: 1457126070
Provider Name (Legal Business Name): JAMIE LYNN EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAMIE LYNN EDWARDS BERGERON

II. Dates (important events)

Enumeration Date: 11/24/2023
Last Update Date: 11/24/2023
Certification Date: 11/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 PARKWOOD DR
SIX LAKES MI
48886-9786
US

IV. Provider business mailing address

712 PARKWOOD DR
SIX LAKES MI
48886-9786
US

V. Phone/Fax

Practice location:
  • Phone: 616-824-6826
  • Fax:
Mailing address:
  • Phone: 616-824-6826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: