Provider Demographics
NPI:1376235184
Name:JODI M FOURT
Entity Type:Organization
Organization Name:JODI M FOURT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/PSYD
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:FOURT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:224-703-5595
Mailing Address - Street 1:13 CROSSVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-5841
Mailing Address - Country:US
Mailing Address - Phone:224-703-5595
Mailing Address - Fax:
Practice Address - Street 1:1530 N RANDALL RD STE 220
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7879
Practice Address - Country:US
Practice Address - Phone:224-703-5595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty