Provider Demographics
NPI:1962042184
Name:HELLER, JODY LYNN (SUDP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:HELLER
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 MARTIN WAY E STE 117
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5586
Mailing Address - Country:US
Mailing Address - Phone:360-413-6900
Mailing Address - Fax:
Practice Address - Street 1:6700 MARTIN WAY E STE 117
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5586
Practice Address - Country:US
Practice Address - Phone:360-413-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61015481390200000X, 390200000X
WACP61292665101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)