Basic Information
Provider Information | |||||||||
NPI: | 1467578799 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COUSINS | ||||||||
FirstName: | JODY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6020 RICHMOND HWY | ||||||||
Address2: | STE 102 | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 223032157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4433933653 | ||||||||
FaxNumber: | 8779918997 | ||||||||
Practice Location | |||||||||
Address1: | 1213 24TH STREET | ||||||||
Address2: | SUITE #100 | ||||||||
City: | ANACORTES | ||||||||
State: | WA | ||||||||
PostalCode: | 982212559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602934655 | ||||||||
FaxNumber: | 3605881041 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2007 | ||||||||
LastUpdateDate: | 03/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7939A | WY | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD046860 | DC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 208600000X | 57012332 | OH | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 207Q00000X | D0086550 | MD | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD60132209 | WA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2007259 | 05 | WA |   | MEDICAID |