Provider Demographics
NPI:1720389208
Name:CONRAD, JODIE MARIE
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:MARIE
Last Name:CONRAD
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 1:6154 MISSION GORGE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3435
Mailing Address - Country:US
Mailing Address - Phone:616-285-1718
Mailing Address - Fax:616-285-3803
Practice Address - Street 1:6154 MISSION GORGE RD STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3435
Practice Address - Country:US
Practice Address - Phone:616-285-1718
Practice Address - Fax:616-285-3803
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000000Medicaid