Provider Demographics
NPI:1508369356
Name:DIXON, JODIE M (PT)
Entity Type:Individual
Prefix:DR
First Name:JODIE
Middle Name:M
Last Name:DIXON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 HALL ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3850
Mailing Address - Country:US
Mailing Address - Phone:616-450-0989
Mailing Address - Fax:
Practice Address - Street 1:1840 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2921
Practice Address - Country:US
Practice Address - Phone:616-267-3144
Practice Address - Fax:616-267-3144
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015528225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist