Provider Demographics
NPI:1740446517
Name:MOODY, JEANETTE FAYE (COTA)
Entity type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:FAYE
Last Name:MOODY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11539 COASTAL WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-5216
Mailing Address - Country:US
Mailing Address - Phone:317-894-3503
Mailing Address - Fax:
Practice Address - Street 1:8025 DOUBLE DAY DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2016
Practice Address - Country:US
Practice Address - Phone:317-543-2649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000106A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant