Provider Demographics
NPI:1144686890
Name:PICKERING, JODY
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:PICKERING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:JEAN
Other - Last Name:RADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:940 LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-3359
Mailing Address - Country:US
Mailing Address - Phone:712-253-6061
Mailing Address - Fax:712-255-7580
Practice Address - Street 1:940 LOGAN ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-3359
Practice Address - Country:US
Practice Address - Phone:712-253-6061
Practice Address - Fax:712-255-7580
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00796225200000X
NE900225200000X
KS14-02204225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant