Healthcare Provider Details

I. General information

NPI: 1992725972
Provider Name (Legal Business Name): JEFF WOOD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/25/2024
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 E ROBINSON ST STE 206B
CARMI IL
62821-1935
US

IV. Provider business mailing address

PO BOX 112
CARMI IL
62821-0112
US

V. Phone/Fax

Practice location:
  • Phone: 407-227-8150
  • Fax:
Mailing address:
  • Phone: 407-227-8150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 5698
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-021154
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: