Provider Demographics
NPI:1942386172
Name:MATHYS, JODI ANN (MSE, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:ANN
Last Name:MATHYS
Suffix:
Gender:F
Credentials:MSE, LPC
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:VANDERHOOF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22308
Mailing Address - Street 2:300 CROOKS STREET
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2308
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-432-5966
Practice Address - Street 1:300 CROOKS STREET
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-432-5966
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4054-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43726400Medicaid