Provider Demographics
NPI:1487734059
Name:TULLY, JODI BETH (LMSW)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:BETH
Last Name:TULLY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:BETH
Other - Last Name:LEITNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:105 SOUTH LAKE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3367
Mailing Address - Country:US
Mailing Address - Phone:518-434-1799
Mailing Address - Fax:518-434-1132
Practice Address - Street 1:105 S LAKE AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3367
Practice Address - Country:US
Practice Address - Phone:518-434-1799
Practice Address - Fax:518-434-1132
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0675081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical