MEDICARE: JODI PROVINCE COUNSELING SERVICES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1710366687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JODI PROVINCE COUNSELING SERVICES PLLC

Provider Business Mailing Address
First Line	:	1260 COLLEGE AVE
Second Line	:	SUITE 1
City	:	WILKESBORO
State	:	NC
Zip	:	28697-2700
Country	:	US
Telephone Number	:	336-526-0073
Fax Number	:	336-526-0036

Provider Business Practice Location Address
First Line	:	2587 PLEASANT RIDGE RD
Second Line	:
City	:	STATE ROAD
State	:	NC
Zip	:	28676-9318
Country	:	US
Telephone Number	:	336-818-0733
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JODI TILLEY PROVINCE
Credential	:
Telephone Number	:	336-818-0733

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	07/27/2023

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