Healthcare Provider Details

I. General information

NPI: 1306489240
Provider Name (Legal Business Name): JERRY DEPOY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29566 NORTHWESTERN HWY STE 100
SOUTHFIELD MI
48034-1036
US

IV. Provider business mailing address

1216 SYCAMORE DR
JENISON MI
49428-8336
US

V. Phone/Fax

Practice location:
  • Phone: 248-301-1098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: