Provider Demographics
NPI:1083066054
Name:HENRY, JODY LEIGH (LAC, LMT)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LEIGH
Last Name:HENRY
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1779 ROUTE 21
Mailing Address - Street 2:
Mailing Address - City:SHORTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14548-9718
Mailing Address - Country:US
Mailing Address - Phone:585-478-4590
Mailing Address - Fax:
Practice Address - Street 1:6271 S VINE VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NY
Practice Address - Zip Code:14507-9761
Practice Address - Country:US
Practice Address - Phone:585-478-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25005777171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist