Healthcare Provider Details

I. General information

NPI: 1649660184
Provider Name (Legal Business Name): JODY PENDLETON PSYD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 HIGH ST
CANON CITY CO
81212-8746
US

IV. Provider business mailing address

2480 HIGH ST
CANON CITY CO
81212-8746
US

V. Phone/Fax

Practice location:
  • Phone: 719-251-0773
  • Fax:
Mailing address:
  • Phone: 719-251-0773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2859
License Number StateCO

VIII. Authorized Official

Name: DR. JODY L PENDLETON
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: PSYD, LPC
Phone: 719-251-0773