Provider Demographics
NPI:1912186792
Name:WILLIS, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:WILLIS
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 1:305 WOOLEY ST
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-3236
Mailing Address - Country:US
Mailing Address - Phone:910-875-5074
Mailing Address - Fax:
Practice Address - Street 1:305 WOOLEY ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3236
Practice Address - Country:US
Practice Address - Phone:910-875-5074
Practice Address - Fax:910-875-7694
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300027KMedicaid