Provider Demographics
NPI:1861050320
Name:CODY, JEWELL
Entity type:Individual
Prefix:
First Name:JEWELL
Middle Name:
Last Name:CODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-4425
Mailing Address - Country:US
Mailing Address - Phone:203-606-3184
Mailing Address - Fax:
Practice Address - Street 1:171 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-4425
Practice Address - Country:US
Practice Address - Phone:203-606-3184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)