Healthcare Provider Details

I. General information

NPI: 1205597168
Provider Name (Legal Business Name): SYDNE JEPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22170 W 9 MILE RD
SOUTHFIELD MI
48033-6007
US

IV. Provider business mailing address

22170 W 9 MILE RD
SOUTHFIELD MI
48033-6007
US

V. Phone/Fax

Practice location:
  • Phone: 248-372-6800
  • Fax:
Mailing address:
  • Phone: 248-372-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704371746
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: