Provider Demographics
NPI:1194050435
Name:JODI PROVINCE COUNSELING SERVICES PLLC
Entity type:Organization
Organization Name:JODI PROVINCE COUNSELING SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER/MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:TILLEY
Authorized Official - Last Name:PROVINCE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, NCC
Authorized Official - Phone:336-818-0733
Mailing Address - Street 1:1260 COLLEGE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-2700
Mailing Address - Country:US
Mailing Address - Phone:336-818-0733
Mailing Address - Fax:336-818-0734
Practice Address - Street 1:1260 COLLEGE AVE STE 1
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-2700
Practice Address - Country:US
Practice Address - Phone:336-818-0733
Practice Address - Fax:336-818-0734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5534101YP2500X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103527Medicaid
NC6112147Medicaid
NC6102745Medicaid
NC6112237Medicaid
NC6106369Medicaid
NC6103333Medicaid
NC6105186Medicaid
NC144VWOtherBCBSNC
NC6107594Medicaid