Healthcare Provider Details

I. General information

NPI: 1407172554
Provider Name (Legal Business Name): JODY L POULTNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W VIRGINIA AVE
NORMAL IL
61761-3666
US

IV. Provider business mailing address

403 W VIRGINIA AVE
NORMAL IL
61761-3666
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-3669
  • Fax: 309-268-3649
Mailing address:
  • Phone: 309-268-3669
  • Fax: 309-268-3649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149013689
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: