Healthcare Provider Details

I. General information

NPI: 1134472954
Provider Name (Legal Business Name): JODY ANN GILES PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 LONE OAK RD
PADUCAH KY
42001-4442
US

IV. Provider business mailing address

754 SHELBY RD
KEVIL KY
42053-8929
US

V. Phone/Fax

Practice location:
  • Phone: 270-562-5112
  • Fax:
Mailing address:
  • Phone: 270-562-5112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1281
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1281
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: