1043244577 NPI number — JODIE MARIE KNOTT PHD

Table of content: JODIE MARIE KNOTT PHD (NPI 1043244577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043244577 NPI number — JODIE MARIE KNOTT PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNOTT
Provider First Name:
JODIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1043244577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 90125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90809-0125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-404-2353
Provider Business Mailing Address Fax Number:
562-795-0676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7872 WALKER STREET
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LA PALMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-490-3428
Provider Business Practice Location Address Fax Number:
714-224-3803
Provider Enumeration Date:
07/10/2006

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: 103T00000X , with the licence number:  PSY20647 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PSY20647 . This is a "BOARD OF PSYCHOLOGY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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