Provider Demographics
NPI:1912949413
Name:JODWAY, KEITH D (LMHC, LCAC)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:D
Last Name:JODWAY
Suffix:
Gender:M
Credentials:LMHC, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-3322
Mailing Address - Country:US
Mailing Address - Phone:574-220-0220
Mailing Address - Fax:574-534-5778
Practice Address - Street 1:209 TANGLEWOOD DR APT C
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1718
Practice Address - Country:US
Practice Address - Phone:574-220-0220
Practice Address - Fax:574-975-7788
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN00228101YA0400X
IN39001485A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN87000367AOtherLICENSED CLINICAL ADDICTION COUNSELOR
IN39001485AOtherLICENSED MENTAL HEALTH COUNSELOR