Provider Demographics
NPI:1710991450
Name:BENTON, JUDY JORDAN (PT, PCS)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:JORDAN
Last Name:BENTON
Suffix:
Gender:F
Credentials:PT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 HERITAGE LN NE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-1255
Mailing Address - Country:US
Mailing Address - Phone:256-235-2524
Mailing Address - Fax:256-236-2573
Practice Address - Street 1:1705 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-3832
Practice Address - Country:US
Practice Address - Phone:256-235-2524
Practice Address - Fax:256-236-2573
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist