Provider Demographics
NPI:1841472586
Name:JONES, JODI POLAHA (PHD)
Entity type:Individual
Prefix:DR
First Name:JODI
Middle Name:POLAHA
Last Name:JONES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:POLAHA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-6464
Mailing Address - Fax:423-439-7118
Practice Address - Street 1:917 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6527
Practice Address - Country:US
Practice Address - Phone:423-439-6464
Practice Address - Fax:423-439-7118
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2737103TC0700X
TNP2737103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1514093Medicaid