Healthcare Provider Details

I. General information

NPI: 1528208055
Provider Name (Legal Business Name): JODY SKAGGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 PAWTUCKET AVE
PAWTUCKET RI
02860-3811
US

IV. Provider business mailing address

166 PAWTUCKET AVE
PAWTUCKET RI
02860-3811
US

V. Phone/Fax

Practice location:
  • Phone: 401-722-4644
  • Fax:
Mailing address:
  • Phone: 401-722-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDP00434
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: