Provider Demographics
NPI:1265781991
Name:BODKINS, JEREMY R (PT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:BODKINS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2135
Mailing Address - Country:US
Mailing Address - Phone:304-363-0050
Mailing Address - Fax:304-363-0046
Practice Address - Street 1:1509 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2135
Practice Address - Country:US
Practice Address - Phone:304-363-0050
Practice Address - Fax:304-363-0046
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003071225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist