Provider Demographics
NPI:1982758694
Name:STAFFORD, JODY LYNN (DPT, MOT, MTC, CEAS)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:DPT, MOT, MTC, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 W HORIZON RIDGE PKWY
Mailing Address - Street 2:#120
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2896
Mailing Address - Country:US
Mailing Address - Phone:702-896-0383
Mailing Address - Fax:702-889-0383
Practice Address - Street 1:2625 W HORIZON RIDGE PKWY
Practice Address - Street 2:#120
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2896
Practice Address - Country:US
Practice Address - Phone:702-896-0383
Practice Address - Fax:702-889-0383
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1719225100000X
NV0663225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV101393Medicare ID - Type UnspecifiedOCCUPATIONAL THERAPY ID
NV101392Medicare ID - Type UnspecifiedPHYSICAL THERAPY ID