Provider Demographics
NPI:1811131873
Name:WALLS, JODI (MA, LMHC)
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 SW 29TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-4297
Mailing Address - Country:US
Mailing Address - Phone:239-272-3027
Mailing Address - Fax:
Practice Address - Street 1:911 SW 29TH TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-4297
Practice Address - Country:US
Practice Address - Phone:239-272-3027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9736171W00000X
FL9376171M00000X
FLMH 9376101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health