Provider Demographics
NPI:1861918484
Name:FLYNN, JODY MAUREEN X (PTA)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:MAUREEN
Last Name:FLYNN
Suffix:X
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 1:10 SYCAMORE CT
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-3512
Mailing Address - Country:US
Mailing Address - Phone:201-497-5841
Mailing Address - Fax:
Practice Address - Street 1:160 PARIS AVE STE 2
Practice Address - Street 2:
Practice Address - City:NORTHVALE
Practice Address - State:NJ
Practice Address - Zip Code:07647-2043
Practice Address - Country:US
Practice Address - Phone:201-767-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPTA40QB00220400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty