Healthcare Provider Details

I. General information

NPI: 1275974842
Provider Name (Legal Business Name): JODI LIN FORTNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

786 WILKINSON PL
LABADIE MO
63055-1057
US

IV. Provider business mailing address

786 WILKINSON PL
LABADIE MO
63055-1057
US

V. Phone/Fax

Practice location:
  • Phone: 636-667-9292
  • Fax:
Mailing address:
  • Phone: 636-667-9292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2010013715
License Number StateMO

VIII. Authorized Official

Name: JODI LIN FORTNER
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 636-667-9292