Provider Demographics
NPI:1588688147
Name:SLADICK, JEANETTE K (PA)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:K
Last Name:SLADICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:TRAUMA SERVICES
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-982-5440
Practice Address - Fax:313-982-5445
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN10112363A00000X
MI5601005370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA416564100Medicaid
MNQ63758Medicare UPIN
MN970002493Medicare ID - Type Unspecified