Provider Demographics
NPI:1982021499
Name:CROCKFORD, JODI
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:
Last Name:CROCKFORD
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 1:2015 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7460
Mailing Address - Country:US
Mailing Address - Phone:505-326-2695
Mailing Address - Fax:
Practice Address - Street 1:2015 E 12TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-7460
Practice Address - Country:US
Practice Address - Phone:505-326-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44933Medicaid