Provider Demographics
NPI:1912338823
Name:WEITZ, JODI (LAC)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:
Last Name:WEITZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2763
Mailing Address - Country:US
Mailing Address - Phone:415-457-7762
Mailing Address - Fax:
Practice Address - Street 1:700 E ST STE 100
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2763
Practice Address - Country:US
Practice Address - Phone:415-457-7762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA7126171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist