Provider Demographics
NPI:1275974842
Name:JODI FORTNER LLC
Entity Type:Organization
Organization Name:JODI FORTNER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:LIN
Authorized Official - Last Name:FORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:636-667-9292
Mailing Address - Street 1:1323 JASPER LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4148
Mailing Address - Country:US
Mailing Address - Phone:636-667-9292
Mailing Address - Fax:
Practice Address - Street 1:1323 JASPER LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4148
Practice Address - Country:US
Practice Address - Phone:636-667-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010013715101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty