Provider Demographics
NPI:1861475659
Name:TALBOTT, JODY E (PHD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:E
Last Name:TALBOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 EXECUTIVE DR
Mailing Address - Street 2:SUITE # 204
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-9037
Mailing Address - Country:US
Mailing Address - Phone:239-592-1771
Mailing Address - Fax:239-592-0258
Practice Address - Street 1:4521 EXECUTIVE DR
Practice Address - Street 2:204
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-9037
Practice Address - Country:US
Practice Address - Phone:239-592-1771
Practice Address - Fax:239-592-0258
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7020103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4063ZMedicare UPIN