1265417364 NPI number — JOCELYN J PERDEAU CNP

Table of content: JOCELYN J PERDEAU CNP (NPI 1265417364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265417364 NPI number — JOCELYN J PERDEAU CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERDEAU
Provider First Name:
JOCELYN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265417364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36115 SCHOOLCRAFT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48150-1216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-464-0887
Provider Business Mailing Address Fax Number:
734-402-0254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 CLINTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAUMEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43537-2811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-464-0887
Provider Business Practice Location Address Fax Number:
734-402-0254
Provider Enumeration Date:
12/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN-268844 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN.CNP.07311 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2413070 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01973 . This is a "PARAMOUNT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00193327 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 114719896 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000213037 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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