Provider Demographics
NPI:1417942434
Name:DODD, JACK LEVERN (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:LEVERN
Last Name:DODD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-4561
Mailing Address - Country:US
Mailing Address - Phone:515-292-4474
Mailing Address - Fax:
Practice Address - Street 1:1619 S HIGH AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-8055
Practice Address - Country:US
Practice Address - Phone:515-232-5811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-171362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry