Provider Demographics
NPI:1033464748
Name:BENHAM, JODI (PT)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:BENHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-7661
Mailing Address - Fax:806-687-0534
Practice Address - Street 1:6202 82ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-3691
Practice Address - Country:US
Practice Address - Phone:806-687-8008
Practice Address - Fax:806-687-8009
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPT1218376TX225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX540040100OtherFIRSTCARE
TX877T26OtherBLUE CROSS BLUE SHIELD
TXP01108473OtherMEDICARE RAILROAD
TX370335502Medicaid
TX307335501Medicaid
TX877T26OtherBLUE CROSS BLUE SHIELD