Provider Demographics
NPI:1043896202
Name:JEAN, CODY (LCSW)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 NAGLEE RD # 110
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-7324
Mailing Address - Country:US
Mailing Address - Phone:678-789-6109
Mailing Address - Fax:
Practice Address - Street 1:2655 HENLEY PKWY UNIT 7722
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-2238
Practice Address - Country:US
Practice Address - Phone:678-789-6109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW007304101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health