Provider Demographics
NPI:1770963621
Name:KWACHAK HALL, JODY
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:KWACHAK HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 LAKE TAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6305
Mailing Address - Country:US
Mailing Address - Phone:530-573-7962
Mailing Address - Fax:
Practice Address - Street 1:1900 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6305
Practice Address - Country:US
Practice Address - Phone:530-573-7962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC10549101YP2500X
CALMFT115414106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPCCI1861OtherBBS REGISTRATION NUMBER
CAIMF84997OtherBBS REGISTRATION NUMBER