Provider Demographics
NPI:1124119375
Name:WEBER, JODY (DPT)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:WEBER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S UNIVERSITY AVENUE
Mailing Address - Street 2:STE 150
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916
Mailing Address - Country:US
Mailing Address - Phone:920-885-2663
Mailing Address - Fax:920-885-2466
Practice Address - Street 1:705 S UNIVERSITY AVENUE
Practice Address - Street 2:STE 150
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-885-2663
Practice Address - Fax:920-885-2466
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40205900Medicaid
WI161750013Medicare ID - Type Unspecified