Provider Demographics
NPI:1285842906
Name:GOTTESMAN, JODY LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:GOTTESMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5611 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-1218
Mailing Address - Country:US
Mailing Address - Phone:719-492-5471
Mailing Address - Fax:
Practice Address - Street 1:5611 CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1218
Practice Address - Country:US
Practice Address - Phone:719-492-5471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLCSW 4141041C0700X
CO0003999103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804946Medicare ID - Type UnspecifiedLCSW PIN NO. FOR MEDICARE