Provider Demographics
NPI:1790872612
Name:LANDIS, JODIE ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JODIE
Middle Name:ELIZABETH
Last Name:LANDIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:889 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-4631
Mailing Address - Country:US
Mailing Address - Phone:304-599-2485
Mailing Address - Fax:
Practice Address - Street 1:1085 VAN VOORHIS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3497
Practice Address - Country:US
Practice Address - Phone:304-599-9250
Practice Address - Fax:304-599-9254
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0624235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9400050-0000Medicaid