Provider Demographics
NPI:1629385604
Name:MARSHALL, JODY (LCPC, LCADC)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:LCPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4588 N RANCHO DR STE 12
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3429
Mailing Address - Country:US
Mailing Address - Phone:702-375-2861
Mailing Address - Fax:
Practice Address - Street 1:4588 N RANCHO DR STE 12
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3429
Practice Address - Country:US
Practice Address - Phone:702-375-2861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-11
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty