Provider Demographics
NPI:1316035959
Name:PACKARD, JODENE (MA)
Entity Type:Individual
Prefix:
First Name:JODENE
Middle Name:
Last Name:PACKARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 W ELIZABETH RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1204
Mailing Address - Country:US
Mailing Address - Phone:928-607-8495
Mailing Address - Fax:928-213-9740
Practice Address - Street 1:1006 W ELIZABETH RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1204
Practice Address - Country:US
Practice Address - Phone:928-607-8495
Practice Address - Fax:928-213-9740
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC2508101Y00000X
AZLISAC 1466101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)