Provider Demographics
NPI:1083072938
Name:TINGLE-WILLIS, JODIE DENISE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JODIE
Middle Name:DENISE
Last Name:TINGLE-WILLIS
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 1:343 W KENWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-2127
Mailing Address - Country:US
Mailing Address - Phone:502-644-5796
Mailing Address - Fax:
Practice Address - Street 1:343 W KENWOOD WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-2127
Practice Address - Country:US
Practice Address - Phone:502-644-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-07
Last Update Date:2016-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical