Provider Demographics
NPI:1104236652
Name:PHILLIPS, JODI MUNSON (LSW)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:MUNSON
Last Name:PHILLIPS
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 1:150 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2711
Mailing Address - Country:US
Mailing Address - Phone:208-785-1326
Mailing Address - Fax:208-785-1396
Practice Address - Street 1:150 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2711
Practice Address - Country:US
Practice Address - Phone:208-785-1326
Practice Address - Fax:208-785-1396
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW 31343104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker