Provider Demographics
NPI:1982847760
Name:BAXLEY, JODY WHITE (RPT, MHSA)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:WHITE
Last Name:BAXLEY
Suffix:
Gender:F
Credentials:RPT, MHSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 MOUNTAIN TRCE NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4027
Mailing Address - Country:US
Mailing Address - Phone:770-650-8157
Mailing Address - Fax:
Practice Address - Street 1:2910 MOUNTAIN TRCE NE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4027
Practice Address - Country:US
Practice Address - Phone:770-650-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist