Provider Demographics
NPI:1134150816
Name:HODGES, JEFFREY PAUL (PT, ATC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:PAUL
Last Name:HODGES
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1883 HIGHWAY 43 S
Mailing Address - Street 2:SUITE C
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-8405
Mailing Address - Country:US
Mailing Address - Phone:601-859-2906
Mailing Address - Fax:
Practice Address - Street 1:1883 HIGHWAY 43 S
Practice Address - Street 2:SUITE C
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-8405
Practice Address - Country:US
Practice Address - Phone:601-859-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2160225100000X
MSAT01612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01009819Medicaid
MS512I650001OtherMEDICARE PTAN
MS302I658838OtherMEDICARE PTAN ID#
MS650000278Medicare ID - Type Unspecified
MS01009819Medicaid