Provider Demographics
NPI:1689941528
Name:PETZOLDT, JODY (MA)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:
Last Name:PETZOLDT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 S BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5703
Mailing Address - Country:US
Mailing Address - Phone:573-332-0416
Mailing Address - Fax:573-335-2698
Practice Address - Street 1:340 S BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5703
Practice Address - Country:US
Practice Address - Phone:573-332-0416
Practice Address - Fax:573-335-2698
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011036260101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional