Provider Demographics
NPI:1407114440
Name:BENNETT, JODY CARL (PT)
Entity Type:Individual
Prefix:MR
First Name:JODY
Middle Name:CARL
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3014
Mailing Address - Country:US
Mailing Address - Phone:662-328-1012
Mailing Address - Fax:662-328-1507
Practice Address - Street 1:4010 BIENVILLE BLVD UNIT E
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5990
Practice Address - Country:US
Practice Address - Phone:228-300-6001
Practice Address - Fax:228-300-6005
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3943225100000X
LA11395R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS256212YM43Medicare UPIN