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General NPI Number Information
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NPI Number | 1669191490
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Entity Type | Individual
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Provider Name | JODIE KAY GAINES LCSW, LCAC
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Gender | Female
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Dates
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Enumeration Date | 08/24/2022
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Last Update Date | 02/16/2025
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Provider Practice Location Address
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Address Line | 1708 HIGH ST
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City | SOUTH BEND
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State | IN
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Zip | 46613-2633
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Country | US
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Telephone | 574-406-6180
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Fax |
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Provider Business Mailing Address
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Address Line | 18352 LINDEN RD
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City | ARGOS
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State | IN
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Zip | 46501-9714
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Country | US
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Telephone | 219-307-0668
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 87001775A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34011629A
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License Number State | IN
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