Provider Demographics
NPI:1790853380
Name:FERGUSON, JODY LEE (LMHC)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LEE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11009
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:360-352-2037
Mailing Address - Fax:360-352-0637
Practice Address - Street 1:2222 STATE AVE NE STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4764
Practice Address - Country:US
Practice Address - Phone:360-705-0108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004548101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health