Provider Demographics
NPI:1578303616
Name:DAVIS, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-0271
Mailing Address - Country:US
Mailing Address - Phone:865-585-5404
Mailing Address - Fax:
Practice Address - Street 1:809 N 19TH STREET
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-248-3042
Practice Address - Fax:606-248-3060
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1208505175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist