Provider Demographics
NPI:1689090805
Name:MESBERGEN, JODI LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:LYNN
Last Name:MESBERGEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:JODI
Other - Middle Name:LYNN
Other - Last Name:RUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:286 HOOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3719
Mailing Address - Country:US
Mailing Address - Phone:616-392-2172
Mailing Address - Fax:616-392-1726
Practice Address - Street 1:286 HOOVER BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3719
Practice Address - Country:US
Practice Address - Phone:616-392-2172
Practice Address - Fax:616-392-1726
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001470225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant