1992007702 NPI number — MRS. JODY LYN BRAND LPC, NCC

Table of content: MRS. JODY LYN BRAND LPC, NCC (NPI 1992007702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992007702 NPI number — MRS. JODY LYN BRAND LPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAND
Provider First Name:
JODY
Provider Middle Name:
LYN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, NCC
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:
1992007702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 NORTH 100 EAST
Provider Second Line Business Mailing Address:
P.O. BOX 440219
Provider Business Mailing Address City Name:
KOOSHAREM
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84744-0219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-638-7373
Provider Business Mailing Address Fax Number:
435-638-1105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 CALISTA DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETHEL
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99559-0528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-543-6730
Provider Business Practice Location Address Fax Number:
907-543-6712
Provider Enumeration Date:
11/30/2010

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: 101YM0800X , with the licence number:  6903328-6004 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1020986 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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