Provider Demographics
NPI:1417372756
Name:JODAITIS, MARY-ANN
Entity Type:Individual
Prefix:
First Name:MARY-ANN
Middle Name:
Last Name:JODAITIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY-ANN
Other - Middle Name:
Other - Last Name:BOUTHILLIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:391 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1852
Mailing Address - Country:US
Mailing Address - Phone:860-963-4971
Mailing Address - Fax:860-963-4979
Practice Address - Street 1:391 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1852
Practice Address - Country:US
Practice Address - Phone:860-963-4971
Practice Address - Fax:860-963-4979
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE32489163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)