Provider Demographics
NPI:1982429742
Name:VAN WALLEGHEM, JODI (LMSW)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:VAN WALLEGHEM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12620 W 77TH TER
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66216-3169
Mailing Address - Country:US
Mailing Address - Phone:913-766-2162
Mailing Address - Fax:
Practice Address - Street 1:12760 W 87TH STREET PKWY STE 108
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-2878
Practice Address - Country:US
Practice Address - Phone:913-735-5210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS120861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical