Provider Demographics
NPI:1063283885
Name:OBRIEN, JODIE (LSW)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 NICOLE DR
Mailing Address - Street 2:
Mailing Address - City:MICKLETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08056-1329
Mailing Address - Country:US
Mailing Address - Phone:609-254-8188
Mailing Address - Fax:
Practice Address - Street 1:1 LUPTON AVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-5901
Practice Address - Country:US
Practice Address - Phone:856-693-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05289600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1007637Medicaid