Provider Demographics
NPI:1104684786
Name:LISTER, JODI (AMFT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:LISTER
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:LISTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APCC
Mailing Address - Street 1:10113 ALTA SIERRA DR STE 101
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-6896
Mailing Address - Country:US
Mailing Address - Phone:530-277-7481
Mailing Address - Fax:916-692-1465
Practice Address - Street 1:10113 ALTA SIERRA DR STE 101
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95949-6896
Practice Address - Country:US
Practice Address - Phone:530-277-7481
Practice Address - Fax:916-692-1465
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT145047106H00000X
CAAPCC15695101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional