Provider Demographics
NPI:1699805689
Name:FRY, JODY (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JODY
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-5778
Mailing Address - Country:US
Mailing Address - Phone:765-674-2208
Mailing Address - Fax:765-674-3273
Practice Address - Street 1:5230 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5778
Practice Address - Country:US
Practice Address - Phone:765-674-2208
Practice Address - Fax:765-674-3273
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004934A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000361580OtherBLUE CROSS BLUE SHIELD
IN000000361580OtherBLUE CROSS BLUE SHIELD