Provider Demographics
NPI:1821115049
Name:CAVANAUGH, JODI (MS, LLP, CSP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:MS, LLP, CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 W BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-5516
Mailing Address - Country:US
Mailing Address - Phone:810-287-4928
Mailing Address - Fax:810-257-1310
Practice Address - Street 1:1057 E COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48505-1501
Practice Address - Country:US
Practice Address - Phone:810-287-4928
Practice Address - Fax:810-257-1310
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361000458103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist