Provider Demographics
NPI:1639693906
Name:GRANT, JODI LYNN (ATC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:GRANT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31300 RANCHO COMMUNITY WAY
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-2805
Mailing Address - Country:US
Mailing Address - Phone:951-326-9440
Mailing Address - Fax:
Practice Address - Street 1:31300 RANCHO COMMUNITY WAY
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2805
Practice Address - Country:US
Practice Address - Phone:951-326-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
8902190992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer