Provider Demographics
NPI:1104816347
Name:HANSEN, JODY (MA, LPC, NCC)
Entity type:Individual
Prefix:MS
First Name:JODY
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 REMINGTON WAY DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6379
Mailing Address - Country:US
Mailing Address - Phone:636-230-9258
Mailing Address - Fax:
Practice Address - Street 1:14500 S OUTER 40 RD STE 108
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5736
Practice Address - Country:US
Practice Address - Phone:314-488-8798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014183101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO574624000OtherMAGELLAN
MO025825OtherVMC
MO241027937OtherUNITED HEALTH CARE
MO246952OtherCOMPSYCH