1194050435 NPI number — JODI PROVINCE COUNSELING SERVICES PLLC

Table of content: (NPI 1194050435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194050435 NPI number — JODI PROVINCE COUNSELING SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JODI PROVINCE COUNSELING SERVICES PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1194050435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1260 COLLEGE AVE STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILKESBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28697-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-818-0733
Provider Business Mailing Address Fax Number:
336-818-0734

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1260 COLLEGE AVE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKESBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28697-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-818-0733
Provider Business Practice Location Address Fax Number:
336-818-0734
Provider Enumeration Date:
10/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PROVINCE
Authorized Official First Name:
JODI
Authorized Official Middle Name:
TILLEY
Authorized Official Title or Position:
ORGANIZER/MEMBER
Authorized Official Telephone Number:
336-818-0733

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  5534 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6103527 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6112147 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6102745 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6112237 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6106369 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6103333 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6105186 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 144VW . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6107594 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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