Provider Demographics
NPI:1427194398
Name:VERNAM, JODY ELLEN (LICENSED PROFESSIONA)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:ELLEN
Last Name:VERNAM
Suffix:
Gender:F
Credentials:LICENSED PROFESSIONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 BRECKENRIDGE STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-1025
Mailing Address - Country:US
Mailing Address - Phone:724-458-4990
Mailing Address - Fax:855-775-0514
Practice Address - Street 1:107 BRECKENRIDGE STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-1025
Practice Address - Country:US
Practice Address - Phone:724-458-4990
Practice Address - Fax:855-775-0514
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004344101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1973158OtherHIGHMARK
PA102297262Medicaid