Provider Demographics
NPI:1114322906
Name:HYDE, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:HYDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:H
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34 N 3600 E
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5638
Mailing Address - Country:US
Mailing Address - Phone:208-541-4295
Mailing Address - Fax:
Practice Address - Street 1:1075 S UTAH AVE STE 356
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3334
Practice Address - Country:US
Practice Address - Phone:208-541-4295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-15121101Y00000X
IDLPC-7875101YP2500X
UT340782-6004101YM0800X
AZLPC-17984101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health