Provider Demographics
NPI:1770779654
Name:WALDEN, JODY ILENE
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:ILENE
Last Name:WALDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:ILENE
Other - Last Name:GOLDSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4410 NW 6TH CT
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33066-1522
Mailing Address - Country:US
Mailing Address - Phone:954-984-2984
Mailing Address - Fax:
Practice Address - Street 1:4720 N STATE ROAD 7 BLDG B
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5860
Practice Address - Country:US
Practice Address - Phone:954-497-3856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator