Provider Demographics
NPI:1497594626
Name:BIVENS, JODIE LYNN
Entity type:Individual
Prefix:MRS
First Name:JODIE
Middle Name:LYNN
Last Name:BIVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:LYNN
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1102 HEMLOCK CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-1854
Mailing Address - Country:US
Mailing Address - Phone:270-805-1417
Mailing Address - Fax:
Practice Address - Street 1:1102 HEMLOCK CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-1854
Practice Address - Country:US
Practice Address - Phone:270-805-1417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201158986222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist