Provider Demographics
NPI:1821115049
Name:CAVANAUGH, JODI (MS, LLP, CSP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:MS, LLP, CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 S LINDEN RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3421
Mailing Address - Country:US
Mailing Address - Phone:810-732-3240
Mailing Address - Fax:810-230-0280
Practice Address - Street 1:420 W. 5TH AVENUE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503
Practice Address - Country:US
Practice Address - Phone:810-257-3705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010669103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist