Provider Demographics
NPI:1821599796
Name:GARDNER, JODIE KATHLEEN (RN, LCDC, LPC)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:KATHLEEN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RN, LCDC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 HELENA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2518 HELENA CIRCLE
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606
Practice Address - Country:US
Practice Address - Phone:325-280-1257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX179319164X00000X
TX940974251J00000X
TX77489101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty
No251J00000XAgenciesNursing Care