Provider Demographics
NPI:1003199464
Name:RUDDY, JANA CHRISTINE (PT - PHYSICAL THERAP)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:CHRISTINE
Last Name:RUDDY
Suffix:
Gender:F
Credentials:PT - PHYSICAL THERAP
Other - Prefix:
Other - First Name:JANA
Other - Middle Name:CHRISTINE
Other - Last Name:MANNINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT - PHYSICAL THERAP
Mailing Address - Street 1:407 S. TELEGRAPH RD.
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-1611
Mailing Address - Country:US
Mailing Address - Phone:734-240-1950
Mailing Address - Fax:
Practice Address - Street 1:407 S. TELEGRAPH RD.
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1611
Practice Address - Country:US
Practice Address - Phone:734-240-1950
Practice Address - Fax:734-240-1955
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN225100000X
IN99048678A2255A2300X
MI5501016729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400058377Medicare PIN