Provider Demographics
NPI:1104018142
Name:ROBERTS, JODI LYNN
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 W GRAMERCY PL
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-4968
Mailing Address - Country:US
Mailing Address - Phone:210-805-0915
Mailing Address - Fax:210-805-8205
Practice Address - Street 1:1803 W GRAMERCY PL
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-4968
Practice Address - Country:US
Practice Address - Phone:210-805-0915
Practice Address - Fax:210-805-8205
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61347101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional