Provider Demographics
NPI:1265752398
Name:PODOLSKY, JESSICA (PHD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:PODOLSKY
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:PO BOX 272917
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33427-2917
Mailing Address - Country:US
Mailing Address - Phone:305-401-4180
Mailing Address - Fax:
Practice Address - Street 1:5718 WOODFIELD PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-9426
Practice Address - Country:US
Practice Address - Phone:305-401-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 8097103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist