Provider Demographics
NPI:1992800551
Name:CROCKETT, JODI LYNN (PT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:BIG STONE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57216-8237
Mailing Address - Country:US
Mailing Address - Phone:605-541-1140
Mailing Address - Fax:218-233-8545
Practice Address - Street 1:2401 41ST ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7783
Practice Address - Country:US
Practice Address - Phone:701-478-7868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6503225100000X
ND1288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55086Medicaid
MN318295900Medicaid
MN650001327Medicare ID - Type Unspecified