Provider Demographics
NPI:1790249969
Name:JODI PROVINCE COUNSELING SERVICES PLLC
Entity Type:Organization
Organization Name:JODI PROVINCE COUNSELING SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:TILLEY
Authorized Official - Last Name:PROVINCE
Authorized Official - Suffix:
Authorized Official - Credentials:LPCS
Authorized Official - Phone:336-818-0733
Mailing Address - Street 1:1260 COLLEGE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-2700
Mailing Address - Country:US
Mailing Address - Phone:336-818-0733
Mailing Address - Fax:336-818-0734
Practice Address - Street 1:714 CAROLINA AVE STE A
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-7760
Practice Address - Country:US
Practice Address - Phone:336-818-0733
Practice Address - Fax:336-818-0734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty