MEDICARE: MS. JODI LYN SUCKNEY LCSW, CAC III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	5238	CO
2	1041C0700X	Clinical Social Worker	1289	CO

General Provider Information

NPI Number	:	1144527748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JODI LYN SUCKNEY LCSW, CAC III

Provider Business Mailing Address
First Line	:	2121 E 18TH AVE
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80206-1127
Country	:	US
Telephone Number	:	303-355-1014
Fax Number	:	303-355-0899

Provider Business Practice Location Address
First Line	:	2121 E 18TH AVE
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80206-1127
Country	:	US
Telephone Number	:	303-355-1014
Fax Number	:	303-355-0899

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2011
Last Update Date	:	02/16/2011

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