Provider Demographics
NPI:1780053868
Name:JODI LIETZ COUNSELING, LLC
Entity type:Organization
Organization Name:JODI LIETZ COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT INTERN
Authorized Official - Phone:360-608-1010
Mailing Address - Street 1:1500 SW 11TH AVE
Mailing Address - Street 2:UNIT 2701
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-3532
Mailing Address - Country:US
Mailing Address - Phone:360-608-1010
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST
Practice Address - Street 2:SUITE 557
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2543
Practice Address - Country:US
Practice Address - Phone:503-710-9099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR3860251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health