Provider Demographics
NPI:1053783092
Name:LOOMANS, JODIE
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:LOOMANS
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 1:3283 122ND AVE
Mailing Address - Street 2:PO DRAWER 130
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9511
Mailing Address - Country:US
Mailing Address - Phone:616-403-7102
Mailing Address - Fax:
Practice Address - Street 1:3283 122ND AVE
Practice Address - Street 2:PO DRAWER 130
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9511
Practice Address - Country:US
Practice Address - Phone:269-686-5124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014757171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI171M00000XMedicaid