Provider Demographics
NPI:1366733545
Name:MACTAVISH, JODIE KIM
Entity type:Individual
Prefix:MS
First Name:JODIE
Middle Name:KIM
Last Name:MACTAVISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3096 I-70 BUSINESS LOOP
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504
Mailing Address - Country:US
Mailing Address - Phone:970-434-8500
Mailing Address - Fax:970-434-8500
Practice Address - Street 1:3096 I-70 BUSINESS LOOP
Practice Address - Street 2:SUITE D
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81504-5774
Practice Address - Country:US
Practice Address - Phone:970-434-8500
Practice Address - Fax:970-434-8500
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COELECTROACUPUNCTURE171100000X
CON/A CERTIFICATION173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No173C00000XOther Service ProvidersReflexologist