Provider Demographics
NPI:1891800702
Name:BRUCKER, JODY BRENT (ATC)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:BRENT
Last Name:BRUCKER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7599 S WILLIAMSBURG ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-9336
Mailing Address - Country:US
Mailing Address - Phone:812-298-8779
Mailing Address - Fax:
Practice Address - Street 1:200 N 7TH ST
Practice Address - Street 2:C-11, ARENA BUILDING
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-1902
Practice Address - Country:US
Practice Address - Phone:812-237-3962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001007A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer