Provider Demographics
NPI:1407166341
Name:PRODIS, JESSICA (LICSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PRODIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-1813
Mailing Address - Country:US
Mailing Address - Phone:413-687-8239
Mailing Address - Fax:
Practice Address - Street 1:30 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-1813
Practice Address - Country:US
Practice Address - Phone:413-687-8239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70042FOtherCOUNTY OF SANTA CRUZ MEDI-CAL PROVIDER #
CAFHC70044FOtherCOUNTY OF SANTA CRUZ MEDI-CAL PROVIDER #
CAZZZ91892ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP #