=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215769054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE WITH A CUP OF JO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2024
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 NORTH WALNUT STREET SUITE 108
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19963-1467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-343-2829
-----------------------------------------------------
Fax | 833-804-2660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 386 WALMART DR STE 7 PMB 18
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19934-1374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-343-2829
-----------------------------------------------------
Fax | 833-804-2660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | JOCELYN G CORDERO
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 808-343-2829
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------