Provider Demographics
NPI:1407635469
Name:DAVIS, JODENE C
Entity Type:Individual
Prefix:
First Name:JODENE
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 NEW LOTS AVE APT 9A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-6957
Mailing Address - Country:US
Mailing Address - Phone:347-382-1625
Mailing Address - Fax:
Practice Address - Street 1:96 NEW LOTS AVE APT 9A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-6957
Practice Address - Country:US
Practice Address - Phone:347-382-1625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health