Provider Demographics
NPI:1982793063
Name:WILTON, JODI LYN (MED, LISAC, LPC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYN
Last Name:WILTON
Suffix:
Gender:F
Credentials:MED, LISAC, LPC
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:LYN
Other - Last Name:LIVERMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, LISAC, LPC
Mailing Address - Street 1:1901 N TREKELL RD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-1770
Mailing Address - Country:US
Mailing Address - Phone:520-421-2566
Mailing Address - Fax:520-421-2775
Practice Address - Street 1:1901 N TREKELL RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-1770
Practice Address - Country:US
Practice Address - Phone:520-421-2566
Practice Address - Fax:520-421-2775
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1101101YA0400X
AZLPC-12135101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional