Healthcare Provider Details

I. General information

NPI: 1538532510
Provider Name (Legal Business Name): JODIANN HULSTEDT MA, MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3493 FAWNRIDGE DR
ROCKFORD IL
61114-5496
US

IV. Provider business mailing address

3493 FAWNRIDGE DR
ROCKFORD IL
61114-5496
US

V. Phone/Fax

Practice location:
  • Phone: 815-997-1043
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166.001043
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: