Provider Demographics
NPI:1093806788
Name:PENA, JODY MARIE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:MARIE
Last Name:PENA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 SW MISTY CRK
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-5297
Mailing Address - Country:US
Mailing Address - Phone:816-224-6576
Mailing Address - Fax:
Practice Address - Street 1:411 OAK ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2598
Practice Address - Country:US
Practice Address - Phone:513-984-1800
Practice Address - Fax:513-984-4909
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist