Provider Demographics
NPI:1780658161
Name:MOLDENHAUER, JODY L (MPT)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:L
Last Name:MOLDENHAUER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N 31ST ST
Mailing Address - Street 2:APT 2
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-5188
Mailing Address - Country:US
Mailing Address - Phone:701-391-5584
Mailing Address - Fax:
Practice Address - Street 1:1033 BASIN AVE
Practice Address - Street 2:HEALTHWAYS
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6649
Practice Address - Country:US
Practice Address - Phone:701-223-6613
Practice Address - Fax:701-221-9114
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1368225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2271970OtherAMERICA'S PPO ID
ND1368OtherPT LICENSE NUMBER
ND2271970OtherAMERICA'S PPO ID
ND1368OtherPT LICENSE NUMBER