Provider Demographics
NPI:1184890550
Name:KUSSIN, JODY (PHD)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:KUSSIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12609 KILLION ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-1534
Mailing Address - Country:US
Mailing Address - Phone:818-414-2279
Mailing Address - Fax:
Practice Address - Street 1:12609 KILLION ST
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-1534
Practice Address - Country:US
Practice Address - Phone:818-414-2279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11937103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist