Provider Demographics
NPI:1962622746
Name:DETWIELER, JODY L (LIMHP, LCSW)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:L
Last Name:DETWIELER
Suffix:
Gender:F
Credentials:LIMHP, LCSW
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:L
Other - Last Name:DYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2608 OLD FAIR RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-5271
Mailing Address - Country:US
Mailing Address - Phone:308-382-5297
Mailing Address - Fax:308-382-5315
Practice Address - Street 1:2608 OLD FAIR RD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-5271
Practice Address - Country:US
Practice Address - Phone:308-382-5297
Practice Address - Fax:308-382-5315
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MO20060224861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025173100Medicaid