Provider Demographics
NPI:1063900223
Name:WEISS, JODI LYNN (MSPT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:WEISS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:LYNN
Other - Last Name:MAZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:1410 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1541
Mailing Address - Country:US
Mailing Address - Phone:248-743-9500
Mailing Address - Fax:
Practice Address - Street 1:1410 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1541
Practice Address - Country:US
Practice Address - Phone:248-743-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501004983OtherBOARD OF PHYSICAL THERAPY