Provider Demographics
NPI:1992742753
Name:EDMONDSON, JEAN A (NP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23829 LITTLE MACK AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1186
Mailing Address - Country:US
Mailing Address - Phone:586-773-1300
Mailing Address - Fax:586-773-1600
Practice Address - Street 1:23829 LITTLE MACK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1186
Practice Address - Country:US
Practice Address - Phone:586-773-1300
Practice Address - Fax:586-773-1600
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJE215622363L00000X
MI4704215622363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008605420OtherBLUE CROSS BLUE SHIELD
MI4761826Medicaid
MI5008605420OtherBLUE CROSS BLUE SHIELD
MIQ51753Medicare UPIN