Provider Demographics
NPI:1811064801
Name:STODDARD, J REED (MSW)
Entity type:Individual
Prefix:
First Name:J
Middle Name:REED
Last Name:STODDARD
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 S MILLHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2221
Mailing Address - Country:US
Mailing Address - Phone:208-496-1100
Mailing Address - Fax:
Practice Address - Street 1:200 SHC
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83460-2020
Practice Address - Country:US
Practice Address - Phone:208-496-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-9451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical