Provider Demographics
NPI:1992033807
Name:PRIES, JODY LANE
Entity Type:Individual
Prefix:MR
First Name:JODY
Middle Name:LANE
Last Name:PRIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8821 51ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2605
Mailing Address - Country:US
Mailing Address - Phone:360-653-3140
Mailing Address - Fax:360-657-4103
Practice Address - Street 1:8821 51ST AVE NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-2605
Practice Address - Country:US
Practice Address - Phone:360-653-3140
Practice Address - Fax:360-657-4103
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00049399101Y00000X
WAHP10001380101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional