Provider Demographics
NPI:1043244577
Name:KNOTT, JODIE MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:MARIE
Last Name:KNOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90125
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90809-0125
Mailing Address - Country:US
Mailing Address - Phone:800-404-2353
Mailing Address - Fax:562-795-0676
Practice Address - Street 1:7872 WALKER STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623
Practice Address - Country:US
Practice Address - Phone:714-490-3428
Practice Address - Fax:714-224-3803
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20647103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY20647OtherBOARD OF PSYCHOLOGY