Provider Demographics
NPI:1285850867
Name:OWENS, JODY (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:OWENS
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 N MAIN ST STE 10
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-1281
Mailing Address - Country:US
Mailing Address - Phone:208-317-6300
Mailing Address - Fax:208-254-3386
Practice Address - Street 1:20 N MAIN ST STE 10
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1281
Practice Address - Country:US
Practice Address - Phone:208-317-6300
Practice Address - Fax:208-254-3386
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3275101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806997900Medicaid