=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205039021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCCUPATIONAL HEALTH PROGRAM OF JACKSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 LANSING AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-2820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-787-6907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 LANSING AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-2820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-787-6907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLER
-----------------------------------------------------
Name | TRACY STUMP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-787-6907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | DM041794
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------