Provider Demographics
NPI:1720646433
Name:SKENANDORE, JODIE COLLEEN (PCTL)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:COLLEEN
Last Name:SKENANDORE
Suffix:
Gender:F
Credentials:PCTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 W POINT RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1344
Mailing Address - Country:US
Mailing Address - Phone:920-490-3790
Mailing Address - Fax:920-490-3889
Practice Address - Street 1:2640 W POINT RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1344
Practice Address - Country:US
Practice Address - Phone:920-490-3790
Practice Address - Fax:920-490-3889
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI3955-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42125400Medicaid