Provider Demographics
NPI:1053662445
Name:FOURT, JODI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:
Last Name:FOURT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CROSSVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-5841
Mailing Address - Country:US
Mailing Address - Phone:224-703-5595
Mailing Address - Fax:
Practice Address - Street 1:5334 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7320
Practice Address - Country:US
Practice Address - Phone:224-703-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010162103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical