Provider Demographics
NPI:1356098172
Name:MOODY, JANNA (PTA)
Entity Type:Individual
Prefix:
First Name:JANNA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JANNA
Other - Middle Name:
Other - Last Name:BONTREGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:51 WOODCROSS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-2350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 WOODCROSS DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-2350
Practice Address - Country:US
Practice Address - Phone:803-732-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3239225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant