Provider Demographics
NPI:1659583334
Name:PATSCOT, JODY RAE (PTA)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:RAE
Last Name:PATSCOT
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 1:2512 NEW PINE DR
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-1378
Mailing Address - Country:US
Mailing Address - Phone:715-833-0400
Mailing Address - Fax:715-833-0397
Practice Address - Street 1:2512 NEW PINE DR
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-1378
Practice Address - Country:US
Practice Address - Phone:715-833-0400
Practice Address - Fax:715-833-0397
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI760-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40395500Medicaid