Provider Demographics
NPI:1184891590
Name:BOUTOTT, JODI A (PT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:A
Last Name:BOUTOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-8407
Mailing Address - Country:US
Mailing Address - Phone:715-823-3135
Mailing Address - Fax:715-823-1313
Practice Address - Street 1:1625 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-8407
Practice Address - Country:US
Practice Address - Phone:715-823-3135
Practice Address - Fax:715-823-1313
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5055-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40296200Medicaid