Provider Demographics
NPI:1942276928
Name:ECKLEBERRY-HUNT, JODIE GAIL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JODIE
Middle Name:GAIL
Last Name:ECKLEBERRY-HUNT
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 1:2951 W. SHIAWASSEE AVE
Mailing Address - Street 2:PO BOX 403
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430
Mailing Address - Country:US
Mailing Address - Phone:810-714-5809
Mailing Address - Fax:810-714-5809
Practice Address - Street 1:2951 W. SHIAWASSEE AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430
Practice Address - Country:US
Practice Address - Phone:810-714-5809
Practice Address - Fax:810-714-5809
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011429103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP73671Medicare UPIN
MION57800Medicare ID - Type Unspecified