Provider Demographics
NPI:1851331524
Name:ODEFEY, JERRY DAVID (MS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DAVID
Last Name:ODEFEY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:GERALD
Other - Middle Name:DAVID
Other - Last Name:ODEFEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:1000 LANGWORTHY ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7313
Practice Address - Country:US
Practice Address - Phone:563-584-3500
Practice Address - Fax:563-584-3520
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00350103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist