Provider Demographics
NPI:1053755967
Name:SMITH, JODI
Entity type:Individual
Prefix:MS
First Name:JODI
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:WARDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2673 W BOLIVAR AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9761
Mailing Address - Country:US
Mailing Address - Phone:208-659-1705
Mailing Address - Fax:208-667-7557
Practice Address - Street 1:2201 IRONWOOD PL
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2670
Practice Address - Country:US
Practice Address - Phone:208-769-4222
Practice Address - Fax:208-667-7557
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4450101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional