Provider Demographics
NPI:1518490812
Name:HOMMER, JODIE
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:HOMMER
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:PO BOX 30764
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-3012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5915 S REGAL ST STE 304
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-6970
Practice Address - Country:US
Practice Address - Phone:509-416-6065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60634436101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health