Provider Demographics
NPI:1609338425
Name:SPENCER, JODI ANNA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ANNA
Last Name:SPENCER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-6004
Mailing Address - Country:US
Mailing Address - Phone:903-646-2404
Mailing Address - Fax:
Practice Address - Street 1:1011 W LOOP 281 STE 2
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2932
Practice Address - Country:US
Practice Address - Phone:903-646-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77732101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional