Provider Demographics
NPI:1598330037
Name:ELDER, JODIE LYNETTE
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:LYNETTE
Last Name:ELDER
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 670083
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75367-0083
Mailing Address - Country:US
Mailing Address - Phone:469-573-4035
Mailing Address - Fax:
Practice Address - Street 1:7031 MASON DELLS DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-3151
Practice Address - Country:US
Practice Address - Phone:361-319-4608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201089106H00000X
TX61492101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist