Healthcare Provider Details

I. General information

NPI: 1104684786
Provider Name (Legal Business Name): JODI LISTER AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JODI LISTER APCC

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10113 ALTA SIERRA DR STE 101
GRASS VALLEY CA
95949-6896
US

IV. Provider business mailing address

10113 ALTA SIERRA DR STE 101
GRASS VALLEY CA
95949-6896
US

V. Phone/Fax

Practice location:
  • Phone: 530-277-7481
  • Fax: 916-692-1465
Mailing address:
  • Phone: 530-277-7481
  • Fax: 916-692-1465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPCC15695
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT145047
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: