Basic Information
Provider Information | |||||||||
NPI: | 1992007702 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRAND | ||||||||
FirstName: | JODY | ||||||||
MiddleName: | LYN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, NCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 410 NORTH 100 EAST | ||||||||
Address2: | P.O. BOX 440219 | ||||||||
City: | KOOSHAREM | ||||||||
State: | UT | ||||||||
PostalCode: | 847440219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356387373 | ||||||||
FaxNumber: | 4356381105 | ||||||||
Practice Location | |||||||||
Address1: | 1410 CALISTA DRIVE | ||||||||
Address2: |   | ||||||||
City: | BETHEL | ||||||||
State: | AK | ||||||||
PostalCode: | 995590528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075436730 | ||||||||
FaxNumber: | 9075436712 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2010 | ||||||||
LastUpdateDate: | 09/18/2019 | ||||||||
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 | 101YM0800X | 6903328-6004 | UT | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1020986 | 05 | AK |   | MEDICAID |