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General NPI Number Information
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NPI Number | 1295207991
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Entity Type | Individual
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Provider Name | JACQUELINE HODGES
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Gender | Female
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Dates
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Enumeration Date | 12/19/2018
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Last Update Date | 12/19/2018
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Provider Practice Location Address
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Address Line | 15404 ILENE ST
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City | DETROIT
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State | MI
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Zip | 48238-1042
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Country | US
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Telephone | 313-316-6357
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Fax |
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Provider Business Mailing Address
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Address Line | 16845 LINWOOD ST
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City | DETROIT
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State | MI
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Zip | 48221-3126
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WC0400X
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Taxonomy Name | Case Management Registered Nurse
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License Number | 4704305533
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License Number State | MI
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