Basic Information
Provider Information | |||||||||
NPI: | 1265417364 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PERDEAU | ||||||||
FirstName: | JOCELYN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | F.N.P, R.N., C.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 36115 SCHOOLCRAFT RD | ||||||||
Address2: |   | ||||||||
City: | LIVONIA | ||||||||
State: | MI | ||||||||
PostalCode: | 481501216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7344640887 | ||||||||
FaxNumber: | 7344020254 | ||||||||
Practice Location | |||||||||
Address1: | 111 CLINTON ST | ||||||||
Address2: |   | ||||||||
City: | MAUMEE | ||||||||
State: | OH | ||||||||
PostalCode: | 435372811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7344640887 | ||||||||
FaxNumber: | 7344020254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2005 | ||||||||
LastUpdateDate: | 08/06/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-268844 | OH | Y |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | NP07311 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 000000213037 | 01 | OH | ANTHEM | OTHER | 01973 | 01 | OH | PARAMOUNT | OTHER | 114719896 | 05 | MI |   | MEDICAID | 2413070 | 05 | OH |   | MEDICAID | P00193327 | 01 | OH | RAILROAD MEDICARE | OTHER |