Provider Demographics
NPI:1104427715
Name:RODMAN, JERALD (LICSW)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:
Last Name:RODMAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 KRISTINE CT
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-8808
Mailing Address - Country:US
Mailing Address - Phone:509-956-9286
Mailing Address - Fax:
Practice Address - Street 1:2565 KRISTINE CT
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8808
Practice Address - Country:US
Practice Address - Phone:509-956-9286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW610554831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical