Healthcare Provider Details

I. General information

NPI: 1275005068
Provider Name (Legal Business Name): JENNIFER LEIGH CODY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2583 CHOF TRL
FLAGSTAFF AZ
86005-3737
US

IV. Provider business mailing address

2323 E GREENLAW LN STE 10B
FLAGSTAFF AZ
86004-1849
US

V. Phone/Fax

Practice location:
  • Phone: 928-660-2627
  • Fax:
Mailing address:
  • Phone: 928-522-4517
  • Fax: 928-774-2159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number7682709
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number7682709
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: