Provider Demographics
NPI:1801387196
Name:MATHIS, JODI LYNN
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 S FARRELLY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3050
Mailing Address - Country:US
Mailing Address - Phone:845-217-7844
Mailing Address - Fax:
Practice Address - Street 1:6 ADAMS ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-6012
Practice Address - Country:US
Practice Address - Phone:845-324-1209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist