Provider Demographics
NPI:1609521145
Name:CARSON, JODI LYNN (PMHNP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:CARSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 GROOMS RD # 130
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-5912
Mailing Address - Country:US
Mailing Address - Phone:518-416-0359
Mailing Address - Fax:
Practice Address - Street 1:939 ROUTE 146 STE 620
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3629
Practice Address - Country:US
Practice Address - Phone:518-416-0359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF403865-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health