Provider Demographics
NPI:1720418924
Name:BALCOM-HALL, JODY LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:BALCOM-HALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:LYNN
Other - Last Name:BALCOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:350 ELK ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7351
Mailing Address - Country:US
Mailing Address - Phone:605-343-7262
Mailing Address - Fax:605-343-7293
Practice Address - Street 1:111 NORTH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1163
Practice Address - Country:US
Practice Address - Phone:605-343-0650
Practice Address - Fax:605-342-3692
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD-LPN P006382164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse