Provider Demographics
NPI:1104448018
Name:JOSEPHSON, JODY ELIZABETH
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:ELIZABETH
Last Name:JOSEPHSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 ISLAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-9594
Mailing Address - Country:US
Mailing Address - Phone:734-526-3734
Mailing Address - Fax:734-436-2269
Practice Address - Street 1:7415 DEXTER PINCKNEY RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-7505
Practice Address - Country:US
Practice Address - Phone:734-426-3733
Practice Address - Fax:734-426-2269
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF810377402253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency