Provider Demographics
NPI:1790192854
Name:CODY, JACKIE (EDD; MS ED; ADV)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:
Last Name:CODY
Suffix:
Gender:F
Credentials:EDD; MS ED; ADV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 E 45TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3622
Mailing Address - Country:US
Mailing Address - Phone:718-758-1090
Mailing Address - Fax:
Practice Address - Street 1:1692 E 45TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3622
Practice Address - Country:US
Practice Address - Phone:718-758-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2517101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor