Provider Demographics
NPI:1619837804
Name:AXT, JODY ELIZABETH
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:ELIZABETH
Last Name:AXT
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 1:54 GRIEB TRL
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2659
Mailing Address - Country:US
Mailing Address - Phone:860-793-4206
Mailing Address - Fax:
Practice Address - Street 1:1 HOPE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6374
Practice Address - Country:US
Practice Address - Phone:860-793-4206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-12
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty