Provider Demographics
NPI:1073989372
Name:CHARLES, JODI (PTA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 W SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1374
Mailing Address - Country:US
Mailing Address - Phone:810-714-4616
Mailing Address - Fax:
Practice Address - Street 1:3240 W SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1374
Practice Address - Country:US
Practice Address - Phone:810-714-4616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004673225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant