Provider Demographics
NPI:1013320944
Name:STEVENS, JODY
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:STEVENS
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 1:6460 KROFT RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43760-9707
Mailing Address - Country:US
Mailing Address - Phone:740-644-6958
Mailing Address - Fax:
Practice Address - Street 1:6460 KROFT RD
Practice Address - Street 2:
Practice Address - City:MOUNT PERRY
Practice Address - State:OH
Practice Address - Zip Code:43760-9707
Practice Address - Country:US
Practice Address - Phone:740-644-6958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRG1366893747P1801X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0099693Medicaid
OH0099693OtherLV1