Provider Demographics
NPI:1386465714
Name:RISCEN, JODY (LCADC)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:RISCEN
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 MOSSER RD APT S205
Mailing Address - Street 2:
Mailing Address - City:BREINIGSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18031-1395
Mailing Address - Country:US
Mailing Address - Phone:570-236-4581
Mailing Address - Fax:
Practice Address - Street 1:1063 MOSSER RD APT S205
Practice Address - Street 2:
Practice Address - City:BREINIGSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18031-1395
Practice Address - Country:US
Practice Address - Phone:570-236-4581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00113500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)