Provider Demographics
NPI:1124196555
Name:BLACKLEY, JODI (LMFT)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:BLACKLEY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3805
Mailing Address - Country:US
Mailing Address - Phone:714-992-4656
Mailing Address - Fax:714-992-4673
Practice Address - Street 1:2555 E CHAPMAN AVE STE 617
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3621
Practice Address - Country:US
Practice Address - Phone:714-992-4656
Practice Address - Fax:714-992-4673
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41465106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist