Provider Demographics
NPI:1013302611
Name:ANDERSON, JODI (LPC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N MILWAUKEE ST # 202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-5830
Mailing Address - Country:US
Mailing Address - Phone:262-646-8288
Mailing Address - Fax:
Practice Address - Street 1:2300 RIVERSIDE DR STE 300
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-1900
Practice Address - Country:US
Practice Address - Phone:920-655-0859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6028-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor