Healthcare Provider Details

I. General information

NPI: 1699258681
Provider Name (Legal Business Name): JODY G THORNBURG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 2ND AVE
CHESAPEAKE OH
45619-1134
US

IV. Provider business mailing address

103 2ND AVE
CHESAPEAKE OH
45619-1134
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-1551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.169627
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: