Provider Demographics
NPI:1992007702
Name:BRAND, JODY LYN (LPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:LYN
Last Name:BRAND
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 NORTH 100 EAST
Mailing Address - Street 2:P.O. BOX 440219
Mailing Address - City:KOOSHAREM
Mailing Address - State:UT
Mailing Address - Zip Code:84744-0219
Mailing Address - Country:US
Mailing Address - Phone:435-638-7373
Mailing Address - Fax:435-638-1105
Practice Address - Street 1:1410 CALISTA DRIVE
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0528
Practice Address - Country:US
Practice Address - Phone:907-543-6730
Practice Address - Fax:907-543-6712
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6903328-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid