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NPI Code Detail

MEDICARE: JEANNE MARIE NYSTROM

MEDICARE: JEANNE MARIE NYSTROM
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist5501002905MI

General Provider Information

NPI Number : 1972156883
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEANNE MARIE NYSTROM
Provider Business Mailing Address
First Line : 127 MARIGOLD AVE
Second Line :
City : PORTAGE
State : MI
Zip : 49002-6251
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 23332 RED ARROW HWY
Second Line :
City : MATTAWAN
State : MI
Zip : 49071-9703
Country : US
Telephone Number : 269-283-5349
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2019
Last Update Date : 07/19/2019

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Directions to “ JEANNE MARIE NYSTROM ” Practice Location

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