Provider Demographics
NPI:1730334392
Name:HUMPHREY, JODIE (PT, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:PT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:SEEKONK
Mailing Address - State:MA
Mailing Address - Zip Code:02771
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4474
Practice Address - Country:US
Practice Address - Phone:401-729-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10872225100000X, 2251S0007X, 2251X0800X
RI225100000X
MAAT9162255A2300X
246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI659003196Medicare UPIN