Provider Demographics
NPI:1740696962
Name:MICHAEL, JODI (PTA)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6913 WARD RANCH RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OK
Mailing Address - Zip Code:73448-9674
Mailing Address - Country:US
Mailing Address - Phone:580-276-6860
Mailing Address - Fax:
Practice Address - Street 1:1907 REFINERY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2111
Practice Address - Country:US
Practice Address - Phone:940-665-0386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2079441225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant