Provider Demographics
NPI:1134790173
Name:MATHISON, JODI RAE (LPC)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:RAE
Last Name:MATHISON
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 1:17360 CARIBOU DR E
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8552
Mailing Address - Country:US
Mailing Address - Phone:719-761-4249
Mailing Address - Fax:
Practice Address - Street 1:443 CO 105
Practice Address - Street 2:
Practice Address - City:PALMER LAKE
Practice Address - State:CO
Practice Address - Zip Code:80133
Practice Address - Country:US
Practice Address - Phone:719-602-0914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0013952101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional