Provider Demographics
NPI:1235789694
Name:AGNEW, JODI F (PTA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:F
Last Name:AGNEW
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 1:10101 PARK ROWE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-1685
Mailing Address - Country:US
Mailing Address - Phone:225-769-2200
Mailing Address - Fax:225-768-2185
Practice Address - Street 1:15420 S HARRELLS FERRY RD STE D
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2933
Practice Address - Country:US
Practice Address - Phone:225-751-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10400R225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAA10400ROtherLICENSE