Provider Demographics
NPI:1992089932
Name:DUTTENHEFER, JODI LYNN (LSW)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:DUTTENHEFER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 E BROADWAY AVE
Mailing Address - Street 2:SUITE 25
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4086
Mailing Address - Country:US
Mailing Address - Phone:701-224-9611
Mailing Address - Fax:701-224-9747
Practice Address - Street 1:418 E BROADWAY AVE
Practice Address - Street 2:SUITE 25
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4086
Practice Address - Country:US
Practice Address - Phone:701-224-9611
Practice Address - Fax:701-224-9747
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4537104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker